Provider Demographics
NPI:1861705964
Name:CLARK, THEODORE JEFFREY (DC)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JEFFREY
Last Name:CLARK
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 1:17422 108TH AVE SE
Mailing Address - Street 2:101
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5400
Mailing Address - Country:US
Mailing Address - Phone:425-255-0427
Mailing Address - Fax:425-255-1066
Practice Address - Street 1:17422 108TH AVE SE
Practice Address - Street 2:#101
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5400
Practice Address - Country:US
Practice Address - Phone:425-255-0427
Practice Address - Fax:425-255-1066
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-17
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor