Provider Demographics
NPI:1548292428
Name:CLARKE, FRED WALLACE (DC)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:WALLACE
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13849 S MUR LEN RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1652
Mailing Address - Country:US
Mailing Address - Phone:913-764-7575
Mailing Address - Fax:913-764-5643
Practice Address - Street 1:13849 S MUR LEN RD
Practice Address - Street 2:SUITE E
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1652
Practice Address - Country:US
Practice Address - Phone:913-764-7575
Practice Address - Fax:913-764-5643
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-4378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSI248257Medicare ID - Type Unspecified