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General NPI Number Information
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NPI Number | 1225492465
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Entity Type | Organization
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Legal Business Name | ICARUS CHIROPRACTIC LLC
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Dates
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Enumeration Date | 04/13/2016
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Last Update Date | 06/15/2016
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Provider Practice Location Address
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Address Line | 210 6TH ST SUITE 7
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City | CLYMER
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State | PA
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Zip | 15728-1257
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Country | US
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Telephone | 724-422-8070
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Fax | 724-905-8084
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Provider Business Mailing Address
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Address Line | 210 6TH ST SUITE 7
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City | CLYMER
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State | PA
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Zip | 15728-1257
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Country | US
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Telephone | 724-422-8070
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Fax | 724-905-8084
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHNATHAN CLARK
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Credential | DC
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Telephone | 724-422-8070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | DC011132
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License Number State | PA
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