Provider Demographics
NPI:1902899479
Name:CLARK, KRISTENE KAE (DC)
Entity Type:Individual
Prefix:DR
First Name:KRISTENE
Middle Name:KAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KRISTENE
Other - Middle Name:KAE
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:109 RHOADES AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-2625
Mailing Address - Country:US
Mailing Address - Phone:937-548-3610
Mailing Address - Fax:937-548-3615
Practice Address - Street 1:109 RHOADES AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2625
Practice Address - Country:US
Practice Address - Phone:937-548-3610
Practice Address - Fax:937-548-3615
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2063225Medicaid
OH0848291Medicare ID - Type Unspecified
OH2063225Medicaid