Basic Information
| Provider Information | |||||||||
| NPI: | 1982629705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARK CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 SECOND ST | ||||||||
| Address2: | |||||||||
| City: | MORTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017328612 | ||||||||
| FaxNumber: | 6017321957 | ||||||||
| Practice Location | |||||||||
| Address1: | 36 SECOND ST | ||||||||
| Address2: | |||||||||
| City: | MORTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017328612 | ||||||||
| FaxNumber: | 6017321957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6017328612 | ||||||||
| 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 | 03575 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 09014545 | 05 | MS | MEDICAID |