MEDICARE: CLARK COMMUNITY MENTAL HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	1784	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497297626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK COMMUNITY MENTAL HEALTH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 100
Second Line	:	104 W. MAIN
City	:	PIERCE CITY
State	:	MO
Zip	:	65723-2100
Country	:	US
Telephone Number	:	417-476-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 W MAIN ST
Second Line	:
City	:	PIERCE CITY
State	:	MO
Zip	:	65723-1210
Country	:	US
Telephone Number	:	417-476-1000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BRAD RIDENOUR
Credential	:
Telephone Number	:	417-476-1000

Provider Enumeration Date	:	11/04/2016
Last Update Date	:	11/04/2016

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