=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306364575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK CHIRO S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2017
-----------------------------------------------------
Last Update Date | 09/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2815 83RD ST
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60561-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-481-6690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 841 W MONROE ST APT 2A
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-202-4696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEVIN JOHN CLARK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 630-481-6690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------