Provider Demographics
NPI:1548532831
Name:CLARK CHIROPRACTIC CENTER, LLC
Entity type:Organization
Organization Name:CLARK CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-632-1668
Mailing Address - Street 1:154 WEST ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-4400
Mailing Address - Country:US
Mailing Address - Phone:860-632-1668
Mailing Address - Fax:860-632-1672
Practice Address - Street 1:154 WEST ST
Practice Address - Street 2:SUITE E
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-4400
Practice Address - Country:US
Practice Address - Phone:860-632-1668
Practice Address - Fax:860-632-1672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001321111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U75980OtherLIBERTY MUTUTAL
CT050001321CT02OtherANTHEM BLUE CROSS/BLUE SHIELD
CT4409341-002OtherCIGNA
611244OtherAMERICAN CHIROPRACTIC NETWORK
905871CONNOtherPHCS PRIVATE HEALTHCARE SYSTEMS
P2773574OtherOXFORD
U75980OtherHEALTH MANAGEMENT CENTER
CT1397991OtherAIG
U75980OtherWEBSTER
132100OtherCONNECTICARE
1740360049OtherCHN NHD
44-04334OtherUNITED HEALTHCARE
7139035OtherAETNA
U75980OtherGAB ROBBINS
U75980OtherGAB ROBBINS
611244OtherAMERICAN CHIROPRACTIC NETWORK