MEDICARE: DR. DEIRDRE V CLARK DC, ND, CHT, CCRA

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	111NI0013X	Independent Medical Examiner Chiropractor	5172	NC
2	111NI0013X	Independent Medical Examiner Chiropractor	5171	NC
3	171M00000X	Case Manager/Care Coordinator
4	1744R1102X	Research Study Specialist
5	175F00000X	Naturopath
6	111N00000X	Chiropractor	5172	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5172	OTHER	NC	CHIROPRACTIC LICENSE

General Provider Information

NPI Number	:	1053615989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEIRDRE V CLARK DC, ND, CHT, CCRA

Provider Business Mailing Address
First Line	:	10926 DAVID TAYLOR DR STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-0039
Country	:	US
Telephone Number	:	704-266-3250
Fax Number	:

Provider Business Practice Location Address
First Line	:	10926 DAVID TAYLOR DR STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1042
Country	:	US
Telephone Number	:	704-266-3250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2011
Last Update Date	:	08/27/2020

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Directions to “ DR. DEIRDRE V CLARK DC, ND, CHT, CCRA” Practice Location

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