Healthcare Provider Details

I. General information

NPI: 1225449671
Provider Name (Legal Business Name): DUSTIN J CLARK D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S RACE ST
PORT ANGELES WA
98362-6400
US

IV. Provider business mailing address

601 S RACE ST
PORT ANGELES WA
98362-6400
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-7636
  • Fax:
Mailing address:
  • Phone: 360-452-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR.CH.60465702
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: