Individual
DR. DIANE MARIE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.C.
Contact information
Practice address
4705 S CLYDE MORRIS BLVD, PORT ORANGE, FL 32129-4103
(386) 763-2728
Mailing address
4705 S CLYDE MORRIS BLVD, PORT ORANGE, FL 32129-4103
(386) 763-2728
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
CH5971
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001509400
—
FL
01
—
22574
BCBS
FL
01
—
P00706874
RAILROAD MEDICARE
FL
Enumeration date
01/05/2007
Last updated
12/19/2012
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