Healthcare Provider Details

I. General information

NPI: 1851798292
Provider Name (Legal Business Name): DR. CLARK MANDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 BOSTON RD STE 188
LEXINGTON KY
40514-1502
US

IV. Provider business mailing address

3650 BOSTON RD STE 188
LEXINGTON KY
40514-1502
US

V. Phone/Fax

Practice location:
  • Phone: 859-263-2774
  • Fax: 859-263-2787
Mailing address:
  • Phone: 859-263-2774
  • Fax: 502-867-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4345
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number205570
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: