Provider Demographics
NPI:1659501534
Name:CLARK SENIOR CARE,INC
Entity Type:Organization
Organization Name:CLARK SENIOR CARE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-454-3709
Mailing Address - Street 1:526 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CALAIS
Mailing Address - State:ME
Mailing Address - Zip Code:04619-1118
Mailing Address - Country:US
Mailing Address - Phone:207-454-3709
Mailing Address - Fax:
Practice Address - Street 1:526 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CALAIS
Practice Address - State:ME
Practice Address - Zip Code:04619-1118
Practice Address - Country:US
Practice Address - Phone:207-454-3709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-25
Last Update Date:2009-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS3154311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME131220001Medicaid