Basic Information
| Provider Information | |||||||||
| NPI: | 1134873011 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARK CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 S FLA ST | ||||||||
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| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527932441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10840 N US HIGHWAY 301 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344843558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527871600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | LOWELL | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3527932441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.