MEDICARE: MR. JOHN GREGORY CLARK D.C.

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	111NX0800X	Orthopedic Chiropractor	17061	CA

General Provider Information

NPI Number	:	1386731677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN GREGORY CLARK D.C.

Provider Business Mailing Address
First Line	:	4678 N 1ST ST
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93726-0903
Country	:	US
Telephone Number	:	559-226-3400
Fax Number	:	559-226-3963

Provider Business Practice Location Address
First Line	:	7461 N 1ST ST
Second Line	:	STE 103
City	:	FRESNO
State	:	CA
Zip	:	93720-2850
Country	:	US
Telephone Number	:	559-226-3400
Fax Number	:	559-226-3963

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	01/25/2018

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