NPIMap

Organization Active NPI

Mobile County Board of Health

Doing business as Citronelle Clinic

  • Federally Qualified Health Center (FQHC)
  • Citronelle, AL
National Provider Identifier
1053406280
Registry record updated Apr 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MOBILE COUNTY BOARD OF HEALTH
Doing business as
Citronelle Clinic
Practice address
19250 N Mobile St
Citronelle, AL 36522-2122
Phone
(251) 866-9129
Fax
(251) 866-9121
NPI assigned
Oct 4, 2006
Last updated
Apr 29, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 29, 2021

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

Authorized official

Name
Kelly Warren
Title
Executive Director
Phone
(251) 690-8158

Specialties & licenses 1

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

Addresses

Primary practice location

19250 N Mobile St
Citronelle, AL 36522-2122

Mailing address

PO Box 2867
Mobile, AL 36652-2867
Phone (251) 690-8158

Other identifiers 1

IdentifierTypeStateIssuer
630001013MedicaidAL

Other names 1

  • Citronelle Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120106000592 AL Part A Provider - Federally Qualified Health Center (FQHC) 9931208386 Practice locations: Citronelle, AL
O20180913000728 AL Part B Supplier - Clinic/Group Practice 9931208386 Receives reassigned benefits from 32 practitioners
12 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Mobile, AL; Semmes, AL; Mount Vernon, AL; Citronelle, AL; Bay Minette, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053406280. Details of each certification follow.

Federally qualified health center certification: CCN 011856

Legal name
MOBILE COUNTY BOARD OF HEALTH
Doing business as
MOBILE COUNTY HEALTH DEPARTMENT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1992
Last certification
Oct 1, 1992
Ownership / control type
Non-profit – corporation
Organization structure
OtherNon-profit
Enrollment address
19250 N Mobile St
Citronelle, AL 36522-2122

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 12

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

National Provider Directory

National Provider Directory
Tax ID family
Mobile County Board of Health33 organizations share this tax ID, including this one

Other organizations with this tax ID 32

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

View all 32

Locations

19250 N Mobile St
Citronelle, AL 36522
Phone (251) 866-7454

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Kistra Scott Individual Corporate Officer Jan 1, 2017
Kathy Dunning Individual Corporate Officer Jan 1, 2017
Shantrell Nicks Individual Corporate Director Jan 1, 2020
Jolette Fischtzuir Individual Corporate Officer Jan 1, 2017
Dolores Harvey Individual Corporate Officer Jan 1, 2017
Kelly Warren Individual Corporate DirectorExecutive Director Nov 1, 2019
W-2 Managing EmployeeExecutive Director Nov 1, 2019
Carl Cunningham Individual Corporate Director Jan 1, 2020
Elige Jones Individual Corporate Officer Jan 1, 2017
Julie McGee Individual Corporate OfficerChairperson Jan 1, 2017
April Davis Individual Corporate OfficerSecretary Jan 1, 2017
Polly Rivers Individual Corporate OfficerVice Chairperson Jan 1, 2017
Mobile County Board of Health Organization, Citronelle, AL Operational/Managerial Control May 1, 1991

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mobile County Health DepartmentMobile, AL, CCN 011846 Federally qualified health center Operational/Managerial Control Jun 3, 2015
Mobile County Health DepartmentMount Vernon, AL, CCN 011987 Federally qualified health center Operational/Managerial Control Feb 13, 2012
Mobile County Health DepartmentSemmes, AL, CCN 011988 Federally qualified health center Operational/Managerial Control Feb 13, 2012
Mobile County Health DepartmentMobile, AL, CCN 011986 Federally qualified health center Operational/Managerial Control Feb 13, 2012
Mobile County Health DepartmentMobile, AL, CCN 011007 Federally qualified health center Operational/Managerial Control Oct 15, 2012
Mobile County Health DepartmentMobile, AL, CCN 011019 Federally qualified health center Operational/Managerial Control May 1, 1991

Owned or controlled facilities with NPI records 6

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 6

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 6

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": "1159920000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619654400000",
    "number": "1053406280",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2867",
            "city": "MOBILE",
            "state": "AL",
            "postal_code": "366522867",
            "telephone_number": "251-690-8158",
            "fax_number": "251-690-8853"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19250 N MOBILE ST",
            "city": "CITRONELLE",
            "state": "AL",
            "postal_code": "365222122",
            "telephone_number": "251-866-9129",
            "fax_number": "251-866-9121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOBILE COUNTY BOARD OF HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-04",
        "last_updated": "2021-04-29",
        "certification_date": "2021-04-29",
        "status": "A",
        "authorized_official_last_name": "WARREN",
        "authorized_official_first_name": "KELLY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "251-690-8158"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "630001013",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Citronelle Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Citronelle Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Citronelle, AL

Sources for this page

Verify at the official NPI Registry.