Provider Demographics
NPI:1982629705
Name:CLARK CLINIC, INC
Entity Type:Organization
Organization Name:CLARK CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-732-8612
Mailing Address - Street 1:36 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-3424
Mailing Address - Country:US
Mailing Address - Phone:601-732-8612
Mailing Address - Fax:601-732-1957
Practice Address - Street 1:36 SECOND ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-3424
Practice Address - Country:US
Practice Address - Phone:601-732-8612
Practice Address - Fax:601-732-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03575261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014545Medicaid
MS09014545Medicaid