Provider Demographics
NPI:1831481688
Name:CLARK FAMILY CARE, LLC
Entity Type:Organization
Organization Name:CLARK FAMILY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-356-2020
Mailing Address - Street 1:4240 BLUE RIDGE BLVD
Mailing Address - Street 2:SUITE 611
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64133-1713
Mailing Address - Country:US
Mailing Address - Phone:816-356-2020
Mailing Address - Fax:816-356-2022
Practice Address - Street 1:4240 BLUE RIDGE BLVD
Practice Address - Street 2:SUITE 611
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64133-1713
Practice Address - Country:US
Practice Address - Phone:816-356-2020
Practice Address - Fax:816-356-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004023907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty