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General NPI Number Information
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NPI Number | 1205958832
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Entity Type | Organization
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Legal Business Name | CLARK CHIROPRACTIC CLINIC PA
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 02/06/2008
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Provider Practice Location Address
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Address Line | 4917 POPLAR SPRINGS DRIVE
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City | MERIDIAN
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State | MS
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Zip | 39305
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Country | US
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Telephone | 601-482-0716
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Fax | 601-482-0726
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Provider Business Mailing Address
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Address Line | 4917 POPLAR SPRINGS DRIVE
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City | MERIDIAN
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State | MS
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Zip | 39305
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Country | US
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Telephone | 601-482-0716
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Fax | 601-482-0726
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Authorized Official
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Title or Position | CHIROPRACTOR PRESIDENT
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Name | DR. RONALD H CLARK
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Credential | DC
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Telephone | 601-482-0716
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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 | 711
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License Number State | MS
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