NPIMap

Organization Active NPI

Tri County Community Health Council Inc

Doing business as CommWell Health of Shallotte

  • Federally Qualified Health Center (FQHC)
  • Shallotte, NC
National Provider Identifier
1003218439
Registry record updated Mar 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC
Doing business as
CommWell Health of Shallotte
Practice address
341A Whiteville Rd NW
Shallotte, NC 28470-4507
Phone
(877) 935-5255
Fax
(910) 236-2118
NPI assigned
Sep 17, 2014
Last updated
Mar 27, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 27, 2024

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

Authorized official

Name
William Clay Ellison
Title
Revenue Cycle Manager
Phone
(910) 567-7065

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

341A Whiteville Rd NW
Shallotte, NC 28470-4507

Mailing address

PO Box 340
Four Oaks, NC 27524-0340
Phone (910) 567-6194

Other identifiers 2

IdentifierTypeStateIssuer
2804165OtherNCMEDICARE PIN
341026OtherMEDICARE OSCAR

Other names 1

  • CommWell Health of Shallotte Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040702000780 NC Part B Supplier - Clinic/Group Practice 2163409558 Receives reassigned benefits from 52 practitioners
19 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Willard, NC; Tar Heel, NC; Smithfield, NC; Shallotte, NC; Dunn, NC; Salemburg, NC; Ocean Isle Beach, NC; Harrells, NC…
O20141226000441 NC Part A Provider - Federally Qualified Health Center (FQHC) 2163409558 Practice locations: Shallotte, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003218439. Details of each certification follow.

Federally qualified health center certification: CCN 341026

Legal name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC
Doing business as
COMMWELL HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 26, 2014
Last certification
Dec 26, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 21, 1977 in NC
Enrollment address
341A Whiteville Rd NW
Shallotte, NC 28470-4507

Other NPIs with the same Medicare PAC ID 15

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

View all 15

Other NPIs on the same Medicare enrollment 19

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 19

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Nancy J Blackman Individual Corporate DirectorBoard of Directors Nov 17, 2005
Phillip E Mills Individual Corporate DirectorBoard of Directors Jul 22, 2004
Vanessa a Burgess Individual Corporate DirectorBoard of Directors Jul 26, 1991
Raymond Lindsey Individual Corporate DirectorBoard of Directors Oct 14, 2010
Kenneth a Cabral Individual Corporate DirectorBoard of Directors Apr 16, 2015
Nathan J Tilghman Individual Corporate DirectorBoard of Directors Jun 20, 1994
Mary Crumpler Individual Corporate DirectorBoard of Directors Mar 17, 2015
Silvia a. Cendejas Individual Corporate DirectorBoard of Directors Dec 15, 2011
Gary Herring Individual Corporate DirectorBoard of Directors Mar 17, 2016
Spencer McAlpine Individual Corporate DirectorBoard of Directors Aug 29, 2013
William Taylor Individual Corporate DirectorBoard of Director May 18, 2017
Jose Garcia Individual Corporate DirectorDirector Aug 1, 2019
Pamela Tripp Individual Corporate OfficerPresident/Ceo Sep 21, 2009
Corporate DirectorPresident/Ceo Sep 21, 2009
W-2 Managing EmployeePresident/Ceo Sep 21, 2009 100%
Mary E Blaizes Individual Corporate DirectorBoard of Directors Jul 17, 1997
William C Ellison Individual Corporate DirectorRevenue Cycle Manager Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 5

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": "1410912000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711497600000",
    "number": "1003218439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 340",
            "city": "FOUR OAKS",
            "state": "NC",
            "postal_code": "275240340",
            "telephone_number": "910-567-6194",
            "fax_number": "910-567-5342"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "341A WHITEVILLE RD NW",
            "city": "SHALLOTTE",
            "state": "NC",
            "postal_code": "284704507",
            "telephone_number": "877-935-5255",
            "fax_number": "910-236-2118"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI COUNTY COMMUNITY HEALTH COUNCIL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-09-17",
        "last_updated": "2024-03-27",
        "certification_date": "2024-03-27",
        "status": "A",
        "authorized_official_last_name": "ELLISON",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "CLAY",
        "authorized_official_title_or_position": "REVENUE CYCLE MANAGER",
        "authorized_official_telephone_number": "910-567-7065"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PIN",
            "identifier": "2804165",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE OSCAR",
            "identifier": "341026",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CommWell Health of Shallotte",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shallotte, NC

Sources for this page

Verify at the official NPI Registry.