1831501501 NPI number — LARK MEDICAL ASSOCIATES, LLC

Table of content: (NPI 1831501501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831501501 NPI number — LARK MEDICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARK MEDICAL ASSOCIATES, 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:
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:
1831501501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLS GAP
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37711-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-393-4052
Provider Business Mailing Address Fax Number:
423-933-2915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 HIGHWAY 11 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BULLS GAP
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37711-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-393-4052
Provider Business Practice Location Address Fax Number:
423-933-2915
Provider Enumeration Date:
05/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSEWRIGHT
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-393-4052

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: APN0000006848 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q009488 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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