Provider Demographics
NPI:1548615024
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:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GENEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-476-1034
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-2100
Mailing Address - Country:US
Mailing Address - Phone:417-476-1034
Mailing Address - Fax:417-476-1082
Practice Address - Street 1:1701 N CENTRAL
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708
Practice Address - Country:US
Practice Address - Phone:417-476-1034
Practice Address - Fax:417-476-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1801807771Medicaid