Provider Demographics
NPI:1083816128
Name:THE KIRK CLINIC LLC
Entity Type:Organization
Organization Name:THE KIRK CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:MERDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-890-3531
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3877
Mailing Address - Country:US
Mailing Address - Phone:229-891-9016
Mailing Address - Fax:229-891-9185
Practice Address - Street 1:8 LAUREL CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6889
Practice Address - Country:US
Practice Address - Phone:229-891-9016
Practice Address - Fax:229-891-9185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA251066475AMedicaid
GA113968Medicare PIN
GA251066475AMedicaid