Provider Demographics
NPI:1801121140
Name:KAREN CLARKE DBA TLC ADULT GROUP HOME
Entity type:Organization
Organization Name:KAREN CLARKE DBA TLC ADULT GROUP HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-426-3496
Mailing Address - Street 1:210 SOUNDWARD LN
Mailing Address - Street 2:
Mailing Address - City:HERTFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27944-9749
Mailing Address - Country:US
Mailing Address - Phone:252-813-5557
Mailing Address - Fax:
Practice Address - Street 1:210 SOUNDWARD LN
Practice Address - Street 2:
Practice Address - City:HERTFORD
Practice Address - State:NC
Practice Address - Zip Code:27944-9749
Practice Address - Country:US
Practice Address - Phone:252-813-5557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-072-008261QM0850X
311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-072-008OtherMENTAL HEALTH STATE LICENSE NUMBER