MEDICARE: BETH ANNE CLARK LMT

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	017514	NY

General Provider Information

NPI Number	:	1376730689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH ANNE CLARK LMT

Provider Business Mailing Address
First Line	:	1953 RIDGE RD
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-3339
Country	:	US
Telephone Number	:	716-675-4134
Fax Number	:	716-675-5733

Provider Business Practice Location Address
First Line	:	1953 RIDGE RD
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-3339
Country	:	US
Telephone Number	:	716-675-4134
Fax Number	:	716-675-5733

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

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	10/01/2007

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