NPIMap

Individual provider Active NPI

Theodore Jeffrey Clark, D.C.

  • Chiropractor
  • Renton, WA
National Provider Identifier
1861705964
Registry record updated Jul 17, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
ChiropractorTaxonomy code 111N00000X
License
2219 Issued in WA
Practice address
17422 108TH Ave SE
#101
Renton, WA 98055-5400
Phone
(425) 255-0427
Fax
(425) 255-1066
NPI assigned
Jul 17, 2010
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jul 17, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Chiropractor 111N00000X 2219 WA Primary

Addresses

Primary practice location

17422 108TH Ave SE
#101
Renton, WA 98055-5400

Mailing address

17422 108TH Ave SE
101
Renton, WA 98055-5400
Phone (425) 255-0427

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
2219WAMDClinical Child & Adolescent Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Clark Chiropractic Inc PastSince Jun 22, 2021 Accepting new patients
Clark Chiropractic Clinic Chiropractor Past Accepting new patients

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1279324800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1279324800000",
    "number": "1861705964",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17422 108TH AVE SE",
            "address_2": "101",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980555400",
            "telephone_number": "425-255-0427",
            "fax_number": "425-255-1066"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17422 108TH AVE SE",
            "address_2": "#101",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980555400",
            "telephone_number": "425-255-0427",
            "fax_number": "425-255-1066"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "THEODORE",
        "middle_name": "JEFFREY",
        "credential": "D.C.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-07-17",
        "last_updated": "2010-07-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "WA",
            "license": "2219",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Renton, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.