NPIMap

Organization Active NPI

Clark Clinic Inc

  • Rural Health Clinic/Center
  • San Antonio, FL
National Provider Identifier
1013540947
Registry record updated Feb 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CLARK CLINIC INC
Practice address
12620 Curley St
San Antonio, FL 33576-8136
Phone
(352) 787-1600
NPI assigned
Feb 19, 2020
Last updated
Feb 19, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 19, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lowell F. ClarkNPI 1336103563
Title
Owner
Phone
(352) 793-2441

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

12620 Curley St
San Antonio, FL 33576-8136

Mailing address

212 S Florida St
Bushnell, FL 33513-6703
Phone (352) 793-2441

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210816001813 FL Part A Provider - Rural Health Clinic 1759278203 Practice locations: San Antonio, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013540947. Details of each certification follow.

Rural health clinic certification: CCN 683849

Legal name
CLARK CLINIC INC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 3, 2024
Last certification
Sep 3, 2024
Ownership / control type
1A
Organization structure
CorporationProprietary
Incorporated
Oct 9, 2002 in FL
Enrollment address
12620 Curley St
Unit 103;104
San Antonio, FL 33576

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2222578Clark Clinic Inc12620 Curley Street, San Antonio, FL 33576Certificate of waiverApr 28, 2027

National Provider Directory

National Provider Directory
Tax ID family
Clark Clinic Inc7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Locations

12620 Curley St
Unit 103104
San Antonio, FL 33576
Phone (352) 787-1600

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Elizabeth Clark Individual 5% Or Greater Direct Ownership InterestOwner Jul 1, 2021 50%
Lowell Frederick Clark Individual 5% Or Greater Direct Ownership InterestPresident Jul 1, 2021 50%
W-2 Managing EmployeePresident Jul 1, 2021 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1582070400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582070400000",
    "number": "1013540947",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "212 S FLORIDA ST",
            "city": "BUSHNELL",
            "state": "FL",
            "postal_code": "335136703",
            "telephone_number": "352-793-2441"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12620 CURLEY ST",
            "city": "SAN ANTONIO",
            "state": "FL",
            "postal_code": "335768136",
            "telephone_number": "352-787-1600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARK CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-02-19",
        "last_updated": "2020-02-19",
        "certification_date": "2020-02-19",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "LOWELL",
        "authorized_official_middle_name": "F.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "352-793-2441"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in San Antonio, FL

Sources for this page

Verify at the official NPI Registry.