1639693492 NPI number — CLARK CLINIC INC

Table of content: (NPI 1639693492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639693492 NPI number — CLARK CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK CLINIC INC
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:
1639693492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 S FLORIDA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUSHNELL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33513-6703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-793-2441
Provider Business Mailing Address Fax Number:
866-407-0034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 W MYERS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASCOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34753-9748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-787-1600
Provider Business Practice Location Address Fax Number:
352-793-3282
Provider Enumeration Date:
08/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
LOWELL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-793-2441

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 660209605 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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