Provider Demographics
NPI:1013540947
Name:CLARK CLINIC INC
Entity Type:Organization
Organization Name:CLARK CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:F
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-793-2441
Mailing Address - Street 1:212 S FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-6703
Mailing Address - Country:US
Mailing Address - Phone:352-793-2441
Mailing Address - Fax:
Practice Address - Street 1:12620 CURLEY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:FL
Practice Address - Zip Code:33576-8136
Practice Address - Country:US
Practice Address - Phone:352-787-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health