1649380502 NPI number — MR. CLARK E WOOLDRIDGE JR. LISW ACP

Table of content: MR. CLARK E WOOLDRIDGE JR. LISW ACP (NPI 1649380502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649380502 NPI number — MR. CLARK E WOOLDRIDGE JR. LISW ACP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOOLDRIDGE
Provider First Name:
CLARK
Provider Middle Name:
E
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LISW ACP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649380502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3519 TRIPP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-359-4127
Provider Business Mailing Address Fax Number:
806-359-4127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 MITCHELL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-681-6745
Provider Business Practice Location Address Fax Number:
505-742-3182
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I2267 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 05339 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 97107 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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