NPIMap

Organization Active NPI

Clark Clinic Inc

  • Rural Health Clinic/Center
  • Bushnell, FL
National Provider Identifier
1376733857
Registry record updated Dec 27, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CLARK CLINIC INC
Practice address
212 S Florida St
Bushnell, FL 33513-6703
Phone
(352) 793-2441
Fax
(352) 793-2649
NPI assigned
Jul 31, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 27, 2007

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

Authorized official

Name
Elizabeth E Folk, ED.D.
Title
President
Phone
(352) 793-2441

Specialties & licenses 1

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

Addresses

Primary practice location

212 S Florida St
Bushnell, FL 33513-6703

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
O20070921000734 FL Part A Provider - Rural Health Clinic 1759278203 Practice locations: Bushnell, FL

Rural health clinic certification: CCN 108972

Legal name
CLARK CLINIC INC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 20, 2004
Last certification
Aug 10, 2023
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Oct 9, 2002 in FL
Enrollment address
212 South Florida Street
Bushnell, FL 33513-6703

Other NPIs with the same Medicare PAC ID 3

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

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

910 W Myers Blvd
Mascotte, FL 34753
Phone (352) 557-8700

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 Contracted Managing EmployeeVice President Apr 12, 2012 50%
5% Or Greater Direct Ownership Interest Apr 12, 2012 50%
Lowell Frederick Clark Individual 5% Or Greater Direct Ownership Interest Oct 9, 2002 50%
Corporate OfficerPresident Oct 9, 2002 50%

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 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1185840000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1198713600000",
    "number": "1376733857",
    "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",
            "fax_number": "352-793-2649"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "212 S FLORIDA ST",
            "city": "BUSHNELL",
            "state": "FL",
            "postal_code": "335136703",
            "telephone_number": "352-793-2441",
            "fax_number": "352-793-2649"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARK CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-31",
        "last_updated": "2007-12-27",
        "status": "A",
        "authorized_official_last_name": "FOLK",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "352-793-2441",
        "authorized_official_credential": "ED.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "FL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bushnell, FL

Sources for this page

Verify at the official NPI Registry.