Provider Demographics
NPI:1245771658
Name:CHAMP CLARK SERVICE COORDINATION
Entity Type:Organization
Organization Name:CHAMP CLARK SERVICE COORDINATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MACLAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-324-6226
Mailing Address - Street 1:912 HIGHWAY 161
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-2433
Mailing Address - Country:US
Mailing Address - Phone:573-324-6226
Mailing Address - Fax:
Practice Address - Street 1:912 HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-2433
Practice Address - Country:US
Practice Address - Phone:573-324-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management