Provider Demographics
NPI:1356400105
Name:CLARK, RONALD CRAIG (DC, PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CRAIG
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-3722
Mailing Address - Country:US
Mailing Address - Phone:706-636-4325
Mailing Address - Fax:706-636-4325
Practice Address - Street 1:200 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3722
Practice Address - Country:US
Practice Address - Phone:706-636-4325
Practice Address - Fax:706-636-4325
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO002251111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGKNMedicare ID - Type UnspecifiedGROUP #
GAT86430Medicare UPIN