Clark Medical Ventures, LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

900176 Issued in KY

Legal business name

CLARK MEDICAL VENTURES, LLC

Doing business as

Clark Family Care

Practice address

174 Pedro Way
Winchester, KY 40391-8354

Phone

(859) 355-5653

NPI assigned

Jun 28, 2013

Last updated

Sep 2, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Brittany Underwood

Title

Credentialing Agent

Phone

(859) 303-8746

Specialties & licenses 12

Addresses

Other names 1

• Clark Family Care Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043650591. Details of each certification follow.

• CCN 183931 Rural health clinic · Active · Name & address match · Details

Rural health clinic certification: CCN 183931

Legal name

CLARK FAMILY CARE

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Jul 26, 2004

Last certification

Sep 18, 2015

Ownership / control type

1B

Most recent change of ownership

Apr 1, 2013 (1 total)

Facility address

174 Pedro Way
Winchester, KY 40391

Locations

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

{
    "created_epoch": "1372377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1630540800000",
    "number": "1043650591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1031 WELLINGTON WAY STE 240",
            "city": "LEXINGTON",
            "state": "KY",
            "postal_code": "405131257",
            "telephone_number": "859-303-8746"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "174 PEDRO WAY",
            "city": "WINCHESTER",
            "state": "KY",
            "postal_code": "403918354",
            "telephone_number": "859-355-5653"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARK MEDICAL VENTURES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-28",
        "last_updated": "2021-09-02",
        "certification_date": "2021-09-02",
        "status": "A",
        "authorized_official_last_name": "UNDERWOOD",
        "authorized_official_first_name": "BRITTANY",
        "authorized_official_title_or_position": "CREDENTIALING AGENT",
        "authorized_official_telephone_number": "859-303-8746"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "KY",
            "license": "900176",
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2100X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Acute Care",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "363LW0102X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Women's Health",
            "state": "KY",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clark Family Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Clark Family Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Clark County Health Department (Clark Middle School)
• Clark County Pharmacy, Inc
• Clark Emergency Physicians
• Clark Family Care
• Clark Infusion Group LLC (Clark Infusion Clinic)
• Clark Pharmacists Group PLLC (Clark County Pharmacy)
• Clark Radiology, PLLC
• Clark Regional Medical Center
• Clark Regional Medical Center, Inc
• Clark Regional Medical Center, Inc

• Rural Health Clinic/Center in Winchester, KY
• Providers in Winchester, KY by specialty
• Rural Health Clinic/Center in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.