Basic Information
| Provider Information | |||||||||
| NPI: | 1639693492 | ||||||||
| EntityType: | 2 | ||||||||
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| 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 | ||||||||
| FaxNumber: | 8664070034 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 W MYERS BLVD | ||||||||
| Address2: | |||||||||
| City: | MASCOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347539748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527871600 | ||||||||
| FaxNumber: | 3527933282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2017 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | LOWELL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3527932441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.