1528254455 NPI number — CCLS, LLC

Table of content: AMANDA LYNN CLARK LPN (NPI 1629792783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528254455 NPI number — CCLS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCLS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SILVER LAKE CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1528254455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
521 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN BUREN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72956-5109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-410-1740
Provider Business Mailing Address Fax Number:
479-410-1596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6006 SE ADAMS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARTLESVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74006-8960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-335-2172
Provider Business Practice Location Address Fax Number:
918-333-4967
Provider Enumeration Date:
09/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HART
Authorized Official First Name:
JOANN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
918-335-2172

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH7406-7406 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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