MEDICARE: DR. CHRISTINA RAE CLARK L.AC. MSOM, DIPL.OM

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	171100000X	Acupuncturist	99088	MT
2	171100000X	Acupuncturist	205587	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99088	OTHER	MT	MONTANA STATE ACUPUNCTURE LICENSE
2	205587	OTHER	OR	OREGON STATE ACUPUNCTURE LICENSE
3	221	OTHER	MT	STATE LICENSE

General Provider Information

NPI Number	:	1922207125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTINA RAE CLARK L.AC. MSOM, DIPL.OM

Provider Business Mailing Address
First Line	:	19926 PORCUPINE DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-2090
Country	:	US
Telephone Number	:	541-961-7947
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 NE 4TH ST STE 2
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-4647
Country	:	US
Telephone Number	:	541-961-7947
Fax Number	:

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

Provider Enumeration Date	:	07/17/2007
Last Update Date	:	10/04/2021

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