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General NPI Number Information
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NPI Number | 1801391719
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Entity Type | Organization
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Legal Business Name | CLARK FAMILY CLINIC, LLC
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Dates
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Enumeration Date | 03/24/2018
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Last Update Date | 03/24/2018
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Provider Practice Location Address
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Address Line | 649B W MCNEAL ST
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City | BOLIVAR
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State | TN
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Zip | 38008-2519
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Country | US
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Telephone | 731-212-3324
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Fax | 731-212-3325
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Provider Business Mailing Address
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Address Line | PO BOX 342
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City | BOLIVAR
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State | TN
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Zip | 38008-0342
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Country | US
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Telephone | 901-500-5766
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Fax | 731-212-3325
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Authorized Official
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Title or Position | FAMILY NURSE PRACITITIONER
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Name | MRS. CHARLENE E CLARK
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Credential | MSN-APRN
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Telephone | 901-500-5766
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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 |
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License Number State |
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