Basic Information
| Provider Information | |||||||||
| NPI: | 1225661481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARK CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527932441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31450 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SORRENTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327769594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527354044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2020 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | LOWELL | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3527932441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.