Provider Demographics
NPI:1861423527
Name:CLARK, SANDRA A (DC)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6646 W JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-8243
Mailing Address - Country:US
Mailing Address - Phone:866-932-9630
Mailing Address - Fax:
Practice Address - Street 1:6646 W JOHNSON RD
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-8243
Practice Address - Country:US
Practice Address - Phone:866-932-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002710A111N00000X, 111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor