Provider Demographics
NPI:1639693492
Name:CLARK CLINIC INC
Entity Type:Organization
Organization Name:CLARK CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:F
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-793-2441
Mailing Address - Street 1:212 S FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-6703
Mailing Address - Country:US
Mailing Address - Phone:352-793-2441
Mailing Address - Fax:866-407-0034
Practice Address - Street 1:910 W MYERS BLVD
Practice Address - Street 2:
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9748
Practice Address - Country:US
Practice Address - Phone:352-787-1600
Practice Address - Fax:352-793-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health