Healthcare Provider Details

I. General information

NPI: 1497201370
Provider Name (Legal Business Name): MATTHEW CLARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 S COMMERCE DR SUITE 155
MURRAY UT
84107-7926
US

IV. Provider business mailing address

5250 S COMMERCE DR SUITE 155
MURRAY UT
84107-7926
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-7776
  • Fax: 385-800-9999
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number9647019-1202
License Number StateUT

VIII. Authorized Official

Name: MATTHEW CLARK
Title or Position: OWNER
Credential: D.C.
Phone: 801-747-7776