1427068626 NPI number — CLARK FAMILY CARE

Table of content: (NPI 1427068626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427068626 NPI number — CLARK FAMILY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK FAMILY CARE
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:
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:
1427068626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 CANARY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40391-1645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-745-4469
Provider Business Mailing Address Fax Number:
859-745-6918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 CANARY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40391-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-745-4469
Provider Business Practice Location Address Fax Number:
859-745-6918
Provider Enumeration Date:
08/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-745-4469

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  38679 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1213053 . This is a "CHA PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 35001700 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000326872 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64075468 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".