=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659578094
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARK RUZICKA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 FRONT ST BX1420
-----------------------------------------------------
City | LEADVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80461-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-486-1175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1420 610 FRONT ST
-----------------------------------------------------
City | LEADVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80461-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NX0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Chiropractor
-----------------------------------------------------
License Number | 2677
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------