| Organization Name: | CLARK FAMILY MEDICINE |
| NPI Number: | 1194199919 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LISA BARDY CLARK (OWNER) |
| Mailing Address: | 12815 Us Highway 98 W Ste 116 Miramar Beach |
| State: | FL US |
| Postal Code: | 325503245 |
| Phone Number: | 8502690111 |
| Fax Number: | 8502690114 |
| NPI Enumeration Date: | 11/17/2015 |
| NPI Last Update Date: | 11/17/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | ME0073997 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |