Healthcare Provider Details

I. General information

NPI: 1922207125
Provider Name (Legal Business Name): CHRISTINA RAE CLARK L.AC. MSOM, DIPL.OM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 GALLATIN PARK DR UNIT 209
BOZEMAN MT
59715-7945
US

IV. Provider business mailing address

1707 PARK VIEW PL
BOZEMAN MT
59715-8378
US

V. Phone/Fax

Practice location:
  • Phone: 541-961-7947
  • Fax: 406-215-1830
Mailing address:
  • Phone: 541-961-7947
  • Fax: 406-215-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number99088
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number205587
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: