Healthcare Provider Details

I. General information

NPI: 1659578094
Provider Name (Legal Business Name): CLARK RUZICKA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 FRONT ST BX1420
LEADVILLE CO
80461-1420
US

IV. Provider business mailing address

PO BOX 1420 610 FRONT ST
LEADVILLE CO
80461-1420
US

V. Phone/Fax

Practice location:
  • Phone: 719-486-1175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number2677
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: