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General NPI Number Information
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NPI Number | 1194199919
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Entity Type | Organization
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Legal Business Name | CLARK FAMILY MEDICINE
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Dates
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Enumeration Date | 11/17/2015
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Last Update Date | 11/17/2015
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Provider Practice Location Address
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Address Line | 12815 US HIGHWAY 98 W STE 116
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City | MIRAMAR BEACH
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State | FL
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Zip | 32550-3245
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Country | US
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Telephone | 850-269-0111
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Fax | 850-269-0114
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Provider Business Mailing Address
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Address Line | 12815 US HIGHWAY 98 W STE 116
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City | MIRAMAR BEACH
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State | FL
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Zip | 32550-3245
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Country | US
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Telephone | 850-269-0111
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Fax | 850-269-0114
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Authorized Official
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Title or Position | OWNER
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Name | DR. LISA BARDY CLARK
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Credential | M.D.
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Telephone | 850-269-0111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME0073997
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License Number State | FL
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