NPIMap

Organization Active NPI

Mountain Comprehensive Care Center, Inc.

Doing business as Homeplace Clinic

  • Federally Qualified Health Center (FQHC)
  • Prestonsburg, KY
National Provider Identifier
1023517679
Registry record updated Feb 13, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
700264 Issued in KY
Legal business name
MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Doing business as
Homeplace Clinic
Homeplace Clinic Prestonsburg
Practice address
104 S Front Ave
Prestonsburg, KY 41653-1614
Phone
(606) 886-8572
Fax
(606) 886-4433
NPI assigned
Feb 9, 2018
Last updated
Feb 13, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
MOUNTAIN COMPREHENSIVE CARE CENTER, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 13, 2018

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

Authorized official

Name
Roxann Cordial
Title
Credentialing
Phone
(606) 886-8572

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 700264 KY Primary

Addresses

Primary practice location

104 S Front Ave
Prestonsburg, KY 41653-1614

Mailing address

104 S Front Ave
Prestonsburg, KY 41653-1614
Phone (606) 886-8572

Other names 2

  • Homeplace Clinic Doing business as
  • Homeplace Clinic Prestonsburg Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040416000380 KY Part B Supplier - Clinic/Group Practice 5294720553 Receives reassigned benefits from 237 practitioners
24 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Paintsville, KY; Pikeville, KY; Prestonsburg, KY; Salyersville, KY; Winchester, KY; Martin, KY; Ashland, KY; Belfry, KY…
O20180828002631 KY Part A Provider - Federally Qualified Health Center (FQHC) 5294720553 Practice locations: Prestonsburg, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1023517679. Details of each certification follow.

Federally qualified health center certification: CCN 181083

Legal name
MOUNTAIN COMPREHENSIVE CARE CENTER INC
Doing business as
HOMEPLACE CLINIC PRESTONSBURG
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 27, 2018
Last certification
Aug 27, 2018
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
May 17, 1966 in KY
Enrollment address
104 S Front Ave
Prestonsburg, KY 41653-1614

Other NPIs with the same Medicare PAC ID 24

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

View all 24

Other NPIs on the same Medicare enrollment 24

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

View all 24

National Provider Directory

National Provider Directory
Tax ID family
Mt Comprehensive Care C48 organizations share this tax ID, including this one
Part of
Mt Comprehensive Care C

Other organizations with this tax ID 47

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

View all 47

Locations

26229 US Highway 119 N
Toler, KY 41514
Phone (606) 237-0020

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Lynette Muncy Individual Corporate DirectorTreasurer Jan 1, 2018
Jim Vanover Individual Corporate DirectorBoard Member Jan 1, 2016
Sara Daniels Individual Corporate DirectorVice Chair Jan 1, 2017
Ancil W Lewis Individual Corporate DirectorBoard Member Jan 1, 2017
Roy Conley Individual Corporate DirectorBoard Member Jan 1, 2016
Lynette Schindler Individual Corporate DirectorBoard Member Jan 1, 2017
Jackie Tackett Individual Corporate DirectorBoard Member Jan 1, 2017
Durward E Hale Individual Corporate DirectorBoard Member Jan 1, 2017
Paula Thompson Individual Corporate DirectorBoard Member Jan 1, 2018
David Tackett Individual Corporate DirectorBoard Member Jan 1, 2014
Teresa Petot Individual Corporate DirectorChair Jan 1, 2018
Shirley Ratcliff Individual Corporate DirectorBoard Member Jan 1, 2015
Amanda Looney Individual W-2 Managing EmployeeFinancial Manager Dec 6, 2025
Promod Bishnoi Individual Corporate OfficerCeo Jul 31, 2008
Corporate DirectorCeo Jul 31, 2008

Practitioners & affiliated clinicians

Practitioners 56

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 56

NPI Registry JSON

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

{
    "created_epoch": "1518134400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1518480000000",
    "number": "1023517679",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 S FRONT AVE",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416531614",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 S FRONT AVE",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416531614",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN COMPREHENSIVE CARE CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOUNTAIN COMPREHENSIVE CARE CENTER, INC.",
        "enumeration_date": "2018-02-09",
        "last_updated": "2018-02-13",
        "status": "A",
        "authorized_official_last_name": "CORDIAL",
        "authorized_official_first_name": "ROXANN",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "606-886-8572"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "KY",
            "license": "700264",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Homeplace Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Homeplace Clinic Prestonsburg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Prestonsburg, KY

Sources for this page

Verify at the official NPI Registry.