=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699027169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEWIS M CLARK DC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 02/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23836 HIGHWAY 59 N
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-9931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-354-8330
-----------------------------------------------------
Fax | 281-354-5592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23836 HIGHWAY 59 N
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-354-8330
-----------------------------------------------------
Fax | 281-354-5592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LEWIS MARTIN CLARK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 281-354-8330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5922
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------