Healthcare Provider Details

I. General information

NPI: 1134051469
Provider Name (Legal Business Name): THOMAS CLARK QBHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PEARSON
BENTON AR
72015-4436
US

IV. Provider business mailing address

110 PEARSON
BENTON AR
72015-4436
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-4224
  • Fax: 501-778-0450
Mailing address:
  • Phone: 501-315-4224
  • Fax: 501-778-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: