Hendricks Community Hospital Assn & Retirement Home
Organization Active NPI Rural Health Clinic/Center · Hendricks, MN
NPI 1013206812 · NPPES record last updated Aug 27, 2012
Key facts
- NPI
- 1013206812
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- HENDRICKS COMMUNITY HOSPITAL ASSN & RETIREMENT HOME
- Practice address
- 501 E Lincoln St
Hendricks, MN 56136-9598 - Phone
- (507) 275-3121
- Fax
- (507) 275-3194
- NPI assigned
- Apr 1, 2011
- Organization subpart
- Yes
- Parent organization (as reported)
- HENDRICKS COMMUNITY HOSPITAL ASSOCIATION
Authorized official
- Name
- Mr. Jeff Gollaher
- Title
- Ceo
- Phone
- (507) 275-3134
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 6
Related certifications (CCN) 1
Practitioners 7
-
Brenda R Bullerman, PA-C
-
Kathryn Jo Christensen, NP-C
-
Tabb McCluskey, D.O.
-
Julie A Cameron, C.N.P.
-
Larry Jay Grong, D.O.
-
Tomasz Piotr Lis, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0405219 | Hendricks Community Hospital Assn | Provider-performed microscopy | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in MN
Rural health clinic certification: CCN 243455
- Legal name
- HENDRICKS COMMUNITY HOSPITAL ASSN & RETIREMENT HOME
- Doing business as
- HENDRICKS CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 1, 2011
- Last certification
- Sep 10, 2012
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Feb 25, 1941 in MN
- Enrollment address
- 501 E Lincoln St
Hendricks, MN 56136-9598 - Related CCNs
- 241339
Rural health clinic certification: CCN 243457
- Legal name
- HENDRICKS COMMUNITY HOSPITAL ASSN & RETIREMENT HOME
- Doing business as
- IVANHOE MEDICAL CENTER
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 23, 2012
- Last certification
- Jan 6, 2012
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Feb 25, 1941 in MN
- Enrollment address
- 315 N Norman St
Ivanhoe, MN 56142-9580 - Related CCNs
- 241339
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Mark Vaneck |
Corporate Director |
Apr 1, 2011 | |
| Dawn Popowski |
Corporate Director |
Jan 1, 2019 | |
| Amy Heidi Fier |
Corporate Director |
Aug 26, 2023 | |
| Travis Olsen |
Corporate Officer |
Jan 1, 2025 | 100% |
| W-2 Managing Employee |
Aug 1, 2020 | 100% | |
| Vince Robinson |
Corporate Director |
Apr 1, 2011 | |
| James Ness |
Corporate Director |
Aug 27, 2015 | |
| Brittany Johnson |
Corporate Director |
Aug 26, 2023 | |
| John Engels |
Corporate Director |
Aug 24, 2017 | |
| Allen Molascon |
Corporate Director |
Apr 1, 2011 | |
| Heather Shaw |
Corporate Director |
Aug 26, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110602000620 | MN | Part B Supplier - Clinic/Group Practice | 9830127356 |
Receives reassigned benefits from 7 practitioners 1 other NPI on this enrollment Practice locations: Hendricks, MN; Ivanhoe, MN |
| O20110622000734 | MN | Part a Provider - Rural Health Clinic | 9830127356 |
1 other NPI on this enrollment Practice locations: Hendricks, MN |
| O20110623000542 | MN | Part a Provider - Rural Health Clinic | 9830127356 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Ivanhoe, MN |
National Provider Directory
- Part of
- White Family Practice C
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
501 E Lincoln St
Hendricks, MN 56136-9598
Mailing address
501 E Lincoln St
PO Box 106
Hendricks, MN 56136-9598
Phone (507) 275-3134
Other names
- Hendricks Clinic
Other providers in Hendricks, MN
- Debra Browning
- Kathryn Jo Christensen
- Rolland C Digre
- Hendricks Clinic PA
- Hendricks Community Hospital Assn & Retirement Home
- Hendricks Community Hospital Assn & Retirement Home
- Hendricks Community Hospital Assn & Retirement Home
- Hendricks Community Hospital Assn & Retirement Home
- Hendricks Community Hospital Assn & Retirement Home
All providers in Hendricks, MN · Rural Health Clinic/Center in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 27, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.