Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 7094 | AZ |
NPI | 1003119272 |
---|---|
Provider Name | Charles Clark JR. |
First Address | Glendale, AZ 85306-1705 |
Second Address | Glendale, AZ 85306-1705 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2010 |
Last Update Date | 08/02/2017 |