1942330782 NPI number — JEFFREY CLARK

Table of content: (NPI 1942330782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942330782 NPI number — JEFFREY CLARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY CLARK
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:
1942330782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5990 SW 28TH ST.
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
TOPEKA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66614-3525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-273-2565
Provider Business Mailing Address Fax Number:
785-273-2567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5990 SW 28TH ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66614-2545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-273-2565
Provider Business Practice Location Address Fax Number:
785-273-2567
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
785-273-2565

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  60087 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116611 . This is a "BLUE CROSS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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