Provider Demographics
NPI:1801391719
Name:CLARK FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:CLARK FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACITITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSN-APRN
Authorized Official - Phone:901-500-5766
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-0342
Mailing Address - Country:US
Mailing Address - Phone:901-500-5766
Mailing Address - Fax:731-212-3325
Practice Address - Street 1:649B W MCNEAL ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2519
Practice Address - Country:US
Practice Address - Phone:731-212-3324
Practice Address - Fax:731-212-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008745Medicaid