NPIMap

Organization Active NPI

Pediatric Associates

Doing business as Red River Health Care

  • Rural Health Clinic/Center
  • Stanton, KY
National Provider Identifier
1013954510
Registry record updated Mar 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
900183 Issued in KY
Legal business name
PEDIATRIC ASSOCIATES
Doing business as
Red River Health Care
Practice address
321C E College Ave
Stanton, KY 40380-2325
Phone
(606) 663-9797
Fax
(606) 663-9470
NPI assigned
Jun 1, 2006
Last updated
Mar 21, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2017

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

Authorized official

Name
Djien Hwat So
Title
Operating Manager
Phone
(606) 432-0174

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 900183 KY Primary
Physician Assistant 363A00000X PA1161 KY
Family Nurse Practitioner 363LF0000X 3006123 KY
Pediatrics Physician 208000000X 900183 KY

Addresses

Primary practice location

321C E College Ave
Stanton, KY 40380-2325

Mailing address

PO Box 2748
Pikeville, KY 41502-2748
Phone (606) 432-3221

Other identifiers 1

IdentifierTypeStateIssuer
35001783MedicaidKY

Other names 1

  • Red River Health Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040503001550 KY Part A Provider - Rural Health Clinic 9436147048 Practice locations: Stanton, KY
O20050211000269 KY Part B Supplier - Clinic/Group Practice 9436147048 Receives reassigned benefits from 14 practitioners
2 other NPIs on this enrollment
Practice locations: Hazard, KY; Stanton, KY; Pikeville, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013954510. Details of each certification follow.

Rural health clinic certification: CCN 183934

Legal name
PEDIATRIC ASSOCIATES
Doing business as
RED RIVER PEDIATRICS
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 2, 2004
Last certification
Jul 30, 2019
Ownership / control type
1C
Organization structure
LLCProprietary
Enrollment address
321-C East College Avenue
Stanton, KY 40380-2325

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 2

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

National Provider Directory

National Provider Directory
Tax ID family
Medical Investment Trust2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Leonor S Pagtakhan So Individual 5% Or Greater Direct Ownership InterestOwner/Member Jan 1, 2024 50%
Djien So Individual 5% Or Greater Direct Ownership InterestAdministrator and Medical Director Oct 1, 2002 50%
W-2 Managing EmployeeAd;MD; Oct 1, 2002 50%

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 14

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.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149120000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1490054400000",
    "number": "1013954510",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2748",
            "city": "PIKEVILLE",
            "state": "KY",
            "postal_code": "415022748",
            "telephone_number": "606-432-3221",
            "fax_number": "606-437-0438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "321C E COLLEGE AVE",
            "city": "STANTON",
            "state": "KY",
            "postal_code": "403802325",
            "telephone_number": "606-663-9797",
            "fax_number": "606-663-9470"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-01",
        "last_updated": "2017-03-21",
        "status": "A",
        "authorized_official_last_name": "SO",
        "authorized_official_first_name": "DJIEN",
        "authorized_official_middle_name": "HWAT",
        "authorized_official_title_or_position": "OPERATING MANAGER",
        "authorized_official_telephone_number": "606-432-0174"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "KY",
            "license": "900183",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "KY",
            "license": "PA1161",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "KY",
            "license": "3006123",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "KY",
            "license": "900183",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "35001783",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Red River Health Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Stanton, KY

Sources for this page

Verify at the official NPI Registry.