=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952555211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK CHIROPRACTIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2008
-----------------------------------------------------
Last Update Date | 11/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6301 EASTRIDGE RD
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79762-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-337-5553
-----------------------------------------------------
Fax | 432-337-6183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6301 EASTRIDGE RD
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79762-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-337-5553
-----------------------------------------------------
Fax | 432-337-6183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. JAMES WILLIAM KIRK
-----------------------------------------------------
Credential | D C
-----------------------------------------------------
Telephone | 432-337-5553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8532
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 7347
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2256
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5928
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------