Provider Demographics
NPI:1669893913
Name:CLARKE, JOSEPH (LAC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 3RD ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-3738
Mailing Address - Country:US
Mailing Address - Phone:323-363-7275
Mailing Address - Fax:
Practice Address - Street 1:2104 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5704
Practice Address - Country:US
Practice Address - Phone:310-828-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15616171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist