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General NPI Number Information
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NPI Number | 1194101824
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Entity Type | Organization
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Legal Business Name | K & L ENTERPRISE
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Dates
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Enumeration Date | 08/04/2015
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Last Update Date | 09/21/2015
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Provider Practice Location Address
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Address Line | 15B LOUDOUN ST SW
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City | LEESBURG
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State | VA
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Zip | 20175-2908
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Country | US
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Telephone | 703-779-7909
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Fax |
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Provider Business Mailing Address
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Address Line | 15B LOUDOUN ST SW
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City | LEESBURG
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State | VA
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Zip | 20175-2908
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Country | US
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Telephone | 703-779-7909
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Fax |
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | DR. KENT EDWARD CLARK
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Credential | DC
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Telephone | 703-779-7909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 0104-557256
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License Number State | VA
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