1548532831 NPI number — CLARK CHIROPRACTIC CENTER, LLC

Table of content: (NPI 1548532831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548532831 NPI number — CLARK CHIROPRACTIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK CHIROPRACTIC CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548532831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 WEST ST
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
CROMWELL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06416-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-632-1668
Provider Business Mailing Address Fax Number:
860-632-1672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
154 WEST ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
CROMWELL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06416-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-632-1668
Provider Business Practice Location Address Fax Number:
860-632-1672
Provider Enumeration Date:
02/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-632-1668

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  001321 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: U75980 . This is a "LIBERTY MUTUTAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050001321CT02 . This is a "ANTHEM BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4409341-002 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 611244 . This is a "AMERICAN CHIROPRACTIC NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 905871CONN . This is a "PHCS PRIVATE HEALTHCARE SYSTEMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P2773574 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: U75980 . This is a "HEALTH MANAGEMENT CENTER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1397991 . This is a "AIG" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: U75980 . This is a "WEBSTER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 132100 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1740360049 . This is a "CHN NHD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44-04334 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7139035 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: U75980 . This is a "GAB ROBBINS" identifier . This identifiers is of the category "OTHER".




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