Provider Demographics
NPI:1497297626
Name:CLARK COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:CLARK COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDENOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-476-1000
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:104 W. MAIN
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-2100
Mailing Address - Country:US
Mailing Address - Phone:417-476-1000
Mailing Address - Fax:
Practice Address - Street 1:104 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PIERCE CITY
Practice Address - State:MO
Practice Address - Zip Code:65723-1210
Practice Address - Country:US
Practice Address - Phone:417-476-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1784251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1801807771Medicaid
MO000015099Medicare UPIN