NPIMap

Organization Active NPI

Hendry County Hospital Authority

Doing business as Dr. James D. Forbes Family Care Center

  • Rural Health Clinic/Center
  • Clewiston, FL
National Provider Identifier
1053331694
Registry record updated Oct 23, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
3995 Issued in FL
Legal business name
HENDRY COUNTY HOSPITAL AUTHORITY
Doing business as
Dr. James D. Forbes Family Care Center
Practice address
500 W Sagamore Ave
Clewiston, FL 33440-3514
Phone
(863) 902-3032
Fax
(863) 983-6655
NPI assigned
Jul 19, 2006
Last updated
Oct 23, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 23, 2012

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

Authorized official

Name
Mr. Lynn W. Beasley
Title
Ceo
Phone
(863) 902-3076

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 3995 FL Primary

Addresses

Primary practice location

500 W Sagamore Ave
Clewiston, FL 33440-3514

Mailing address

500 W Sagamore Ave
Clewiston, FL 33440-3514
Phone (863) 902-3032

Other identifiers 1

IdentifierTypeStateIssuer
253668401MedicaidFL

Other names 1

  • Dr. James D. Forbes Family Care Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031126000106 FL Part B Supplier - Clinic/Group Practice 8022912435 Receives reassigned benefits from 33 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clewiston, FL; Labelle, FL
O20080611000276 FL Part A Provider - Rural Health Clinic 8022912435 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clewiston, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053331694. Details of each certification follow.

Rural health clinic certification: CCN 103422

Legal name
HENDRY COUNTY HOSPITAL AUTHORITY
Doing business as
DR JAMES D FORBES FAMILY CARE CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 1, 1997
Last certification
Dec 15, 2021
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
500 W Sagamore Ave
Clewiston, FL 33440-3514

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

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
David Theroux Individual Corporate OfficerChief Operating Officer Aug 27, 2021
W-2 Managing EmployeeChief Operating Officer Aug 27, 2021
Jennifer Lesley Individual Corporate DirectorPatient Financial Services Director Aug 27, 2021
W-2 Managing EmployeePatient Financial Services Director Aug 27, 2021

Practitioners & affiliated clinicians

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.

NPI Registry JSON

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

{
    "created_epoch": "1153267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350950400000",
    "number": "1053331694",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 W SAGAMORE AVE",
            "city": "CLEWISTON",
            "state": "FL",
            "postal_code": "334403514",
            "telephone_number": "863-902-3032",
            "fax_number": "863-983-6655"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 W SAGAMORE AVE",
            "city": "CLEWISTON",
            "state": "FL",
            "postal_code": "334403514",
            "telephone_number": "863-902-3032",
            "fax_number": "863-983-6655"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HENDRY COUNTY HOSPITAL AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-19",
        "last_updated": "2012-10-23",
        "status": "A",
        "authorized_official_last_name": "BEASLEY",
        "authorized_official_first_name": "LYNN",
        "authorized_official_middle_name": "W.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "863-902-3076",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "FL",
            "license": "3995",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "253668401",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dr. James D. Forbes Family Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clewiston, FL

Sources for this page

Verify at the official NPI Registry.