FCC Medical Clinics LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

Legal business name

FCC MEDICAL CLINICS LLC

Doing business as

FCC Primary Care Clinic

Practice address

900 State Route VV
Kennett, MO 63857-3834

Phone

(573) 559-2365

Fax

(573) 559-2357

NPI assigned

May 21, 2021

Last updated

May 21, 2021By the provider in NPPES

Organization subpart

Yes

Parent organization

FAMILY COUNSELING CENTER, INC.As reported in NPPES

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

Authorized official

Name

Tracy Ellis

Title

Cco

Phone

(573) 888-5925

Specialties & licenses 1

Addresses

Other names 1

• FCC Primary Care Clinic Doing business as

Medicare fee-for-service enrollment

Enrolled in MO2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043885254. Details of each certification follow.

• CCN 793851 Rural health clinic · Active · Details

Rural health clinic certification: CCN 793851

Legal name

FCC MEDICAL CLINICS LLC

Doing business as

FCC PRIMARY CARE CLINIC

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Sep 6, 2019

Last certification

Aug 22, 2022

Ownership / control type

2B

Most recent change of ownership

Sep 1, 2021 (1 total)

Organization structure

LLCNon-profit

Enrollment address

900 State Route VV
Kennett, MO 63857-3834

Other NPIs on the same Medicare enrollment 1

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

• FCC Medical Clinics LLC

  dba FCC Primary Care Clinic Poplar Bluff

  • Internal Medicine Physician
  • Poplar Bluff, MO
  • NPI 1215510490

  O20210707003258

  Same enrollment

Part of

Family Counseling Cente

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Family Counseling Center, Inc.

  dba FCC Primary Care Clinic

  • Rural Health Clinic/Center
  • Kennett, MO
  • NPI 1386101467

  Member Of

  NPD member

All disclosed owners & managing parties 4

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

Owners & managing parties with NPI records 1

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

• Family Counseling Center, Inc.

  • Community/Behavioral Health Agency
  • Kennett, MO
  • NPI 1669477550

  5% Or Greater Direct Ownership Interest

  CMS ownership

Change-of-ownership history 1

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

• Family Counseling Center, Inc.

  dba FCC Primary Care Clinic

  • Rural Health Clinic/Center
  • Kennett, MO
  • NPI 1386101467

  Acquired from, 2021-09-01

  CMS change of ownership

Practitioners 4

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.

• Jennifer Leann Bader, FNP

  • Family Nurse Practitioner
  • Kennett, MO
  • NPI 1114277803
  Medicare reassignment Care Compare group NPD
• Whitney Jo Bradford, APRN

  • Family Nurse Practitioner
  • Kennett, MO
  • NPI 1346736873
  Medicare reassignment Care Compare group NPD
• Sarfaraz A Jasdanwala, MD

  • Internal Medicine Physician
  • Grand Rapids, MI
  • NPI 1851646665

  MO

  Medicare reassignment Care Compare group NPD
• Karl Erik Shanstrom, DO

  • Family Medicine Physician
  • Kennett, MO
  • NPI 1689815201
  Medicare reassignment NPD

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

{
    "created_epoch": "1621555200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621555200000",
    "number": "1043885254",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 71",
            "city": "KENNETT",
            "state": "MO",
            "postal_code": "638570071",
            "telephone_number": "573-559-2365",
            "fax_number": "573-559-2357"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 STATE ROUTE VV",
            "city": "KENNETT",
            "state": "MO",
            "postal_code": "638573834",
            "telephone_number": "573-559-2365",
            "fax_number": "573-559-2357"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FCC MEDICAL CLINICS LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FAMILY COUNSELING CENTER, INC.",
        "enumeration_date": "2021-05-21",
        "last_updated": "2021-05-21",
        "certification_date": "2021-05-04",
        "status": "A",
        "authorized_official_last_name": "ELLIS",
        "authorized_official_first_name": "TRACY",
        "authorized_official_title_or_position": "CCO",
        "authorized_official_telephone_number": "573-888-5925"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FCC Primary Care Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Family Counseling Center, Inc.
• Family Counseling Center, Inc.
• Family Counseling Center, Inc.
• Family Counsiling Center
• Tara Beth Farrell, BS
• FCC Medical Clinics LLC (FCC Primary Care Clinic)
• Monica Featherston
• Tilghman J Feeler, LPC
• Emillie Finley
• Garry Finn, LMSW

• Rural Health Clinic/Center in Kennett, MO
• Providers in Kennett, MO by specialty
• Rural Health Clinic/Center in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.