Provider Demographics
NPI:1326514381
Name:CLARK SUPPORTED LIVING
Entity Type:Organization
Organization Name:CLARK SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ZONDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:773-332-6106
Mailing Address - Street 1:303 MACAW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-6284
Mailing Address - Country:US
Mailing Address - Phone:773-332-6106
Mailing Address - Fax:
Practice Address - Street 1:303 MACAW DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202
Practice Address - Country:US
Practice Address - Phone:773-332-6106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
No174200000XOther Service ProvidersMeals
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child