Provider Demographics
NPI:1912612961
Name:CLARK FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:CLARK FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISHA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:740-685-6800
Mailing Address - Street 1:293 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BYESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43723-1137
Mailing Address - Country:US
Mailing Address - Phone:740-685-6800
Mailing Address - Fax:833-681-2626
Practice Address - Street 1:293 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BYESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43723-1137
Practice Address - Country:US
Practice Address - Phone:740-685-6800
Practice Address - Fax:833-681-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)