NPIMap

Organization Active NPI

Greenwood Leflore Hospital

Doing business as Itta Bena Clinic

  • Rural Health Clinic/Center
  • Itta Bena, MS
National Provider Identifier
1003875394
Registry record updated May 7, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
GREENWOOD LEFLORE HOSPITAL
Doing business as
Itta Bena Clinic
Practice address
103 Basket St
Itta Bena, MS 38941-2801
Phone
(662) 254-7801
NPI assigned
Mar 23, 2006
Last updated
May 7, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 7, 2018

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

Authorized official

Name
Jennifer Dawne Holmes
Title
Cfo
Phone
(662) 459-2603

Specialties & licenses 1

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

Addresses

Primary practice location

103 Basket St
Itta Bena, MS 38941-2801

Mailing address

PO Box 1410
Greenwood, MS 38935-1410
Phone (662) 254-7801

Other identifiers 1

IdentifierTypeStateIssuer
09014635MedicaidMS

Other names 1

  • Itta Bena Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091117000491 MS Part A Provider - Rural Health Clinic 1153399472 Practice locations: Itta Bena, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003875394. Details of each certification follow.

Rural health clinic certification: CCN 253418

Legal name
GREENWOOD LEFLORE HOSPITAL
Doing business as
ITTA BENA CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 26, 1994
Last certification
Jan 19, 2023
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
103 Basket St
Itta Bena, MS 38941-2801
Related CCNs
250099

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D0888439Itta Bena Rural Health Clinic103 Basket Street, Itta Bena, MS 38941AccreditationAug 26, 2026

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://e3f4c88c-f94a-4be5-b4f8-7a469cbd1c2a.gastro.prod.fhir.ema-api.com/fhir/r4/

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Greenwood Leflore Hospital Organization, Greenwood, MS 5% Or Greater Direct Ownership Interest Mar 23, 2006 100%
Harris Powers Individual Corporate DirectorBoard Chairman Sep 18, 2018
Marcus Banks Individual Corporate DirectorBoard Member Sep 18, 2018
City of Greenwood Organization, Greenwood, MS 5% Or Greater Indirect Ownership Interest Mar 23, 2006 50%
Leflore County Board of Supervisors Organization, Greenwood, MS 5% Or Greater Indirect Ownership Interest Mar 23, 2006 50%
Henry Hargrove Individual Corporate DirectorBoard Member Jun 1, 2019
Emma Bell Individual Corporate DirectorBoard Secretary/Treasurer Sep 18, 2018
Jennifer Dawne Holmes Individual Corporate OfficerCfo Oct 26, 2009
W-2 Managing EmployeeCfo Oct 26, 2009
Operational/Managerial ControlCfo Oct 26, 2009
Tracy Shelton Individual Corporate DirectorBoard Member Oct 17, 2019

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
After Hours ClinicGreenwood, MS, CCN 258555 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jun 10, 2009
Jun 10, 2009

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 6

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": "1143072000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1525651200000",
    "number": "1003875394",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1410",
            "city": "GREENWOOD",
            "state": "MS",
            "postal_code": "389351410",
            "telephone_number": "662-254-7801"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 BASKET ST",
            "city": "ITTA BENA",
            "state": "MS",
            "postal_code": "389412801",
            "telephone_number": "662-254-7801"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREENWOOD LEFLORE HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-23",
        "last_updated": "2018-05-07",
        "status": "A",
        "authorized_official_last_name": "HOLMES",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "DAWNE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "662-459-2603"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09014635",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Itta Bena Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Itta Bena Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Itta Bena, MS

Sources for this page

Verify at the official NPI Registry.