Provider Demographics
NPI:1689710006
Name:BETTY ANN CLARK
Entity Type:Organization
Organization Name:BETTY ANN CLARK
Other - Org Name:B.A.C.'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:7045-323-1071
Mailing Address - Street 1:9709 AVENSONG CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8078
Mailing Address - Country:US
Mailing Address - Phone:704-532-1071
Mailing Address - Fax:
Practice Address - Street 1:9709 AVENSONG CROSSING DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8078
Practice Address - Country:US
Practice Address - Phone:704-532-1071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60001581385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409246Medicaid