MEDICARE: MARKET PLACE CHIROPRACTIC WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH00002638	WA

General Provider Information

NPI Number	:	1013160191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARKET PLACE CHIROPRACTIC WELLNESS CENTER

Provider Business Mailing Address
First Line	:	9633 MARKET PLACE
Second Line	:	SUITE #103
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258
Country	:	US
Telephone Number	:	425-335-0300
Fax Number	:	425-335-0302

Provider Business Practice Location Address
First Line	:	9633 MARKET PL
Second Line	:	SUITE #103
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-7944
Country	:	US
Telephone Number	:	425-335-0300
Fax Number	:	425-335-0302

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. JEFFREY PAUL CLARK
Credential	:	D.C.
Telephone Number	:	425-335-0300

Provider Enumeration Date	:	11/03/2008
Last Update Date	:	12/03/2012

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