Healthcare Provider Details

I. General information

NPI: 1912322694
Provider Name (Legal Business Name): CHRISTOPHER W CLARK L.A.T., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

G544 C STREET
CAMP LEJUENE NC
28542
US

IV. Provider business mailing address

SOI-E P.O. BOX 20161
CAMP LEJUENE NC
28542
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-0494
  • Fax:
Mailing address:
  • Phone: 910-449-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number2062
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: