Healthcare Provider Details

I. General information

NPI: 1659783363
Provider Name (Legal Business Name): CLARK CHIROPRACTIC AND MASSAGE PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S RACE ST STE C
PORT ANGELES WA
98362-6400
US

IV. Provider business mailing address

601 S RACE ST STE C
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 Code261Q00000X
TaxonomyClinic/Center
License NumberCHIR.CH.60465702
License Number StateWA

VIII. Authorized Official

Name: DUSTIN CLARK
Title or Position: PRESIDENT
Credential: D.C.
Phone: 360-452-7636