NPIMap

Organization Active NPI

Regional Health Care Clinic, Inc

Doing business as Katy Trail - Prairie Hills

  • Federally Qualified Health Center (FQHC)
  • Versailles, MO
National Provider Identifier
1053694422
Registry record updated Feb 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
REGIONAL HEALTH CARE CLINIC, INC
Doing business as
Katy Trail - Prairie Hills
Practice address
1109 Clay Rd.
Versailles, MO 65084
Phone
(573) 378-2351
NPI assigned
Sep 22, 2011
Last updated
Feb 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2024

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

Authorized official

Name
Michael Waller
Title
Ceo
Phone
(573) 378-2351

Specialties & licenses 1

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

Addresses

Primary practice location

1109 Clay Rd.
Versailles, MO 65084

Mailing address

821 Westwood Dr
Sedalia, MO 65301-2102
Phone (660) 826-4774

Other names 1

  • Katy Trail - Prairie Hills Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20111122000315 MO Part A Provider - Federally Qualified Health Center (FQHC) 8224926092 Practice locations: Versailles, MO
O20111201000035 MO Part B Supplier - Clinic/Group Practice 8224926092 Receives reassigned benefits from 49 practitioners
2 other NPIs on this enrollment
Practice locations: Stover, MO; Versailles, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053694422. Details of each certification follow.

Federally qualified health center certification: CCN 261053

Legal name
REGIONAL HEALTH CARE CLINIC INC
Doing business as
KATY TRAIL COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 5, 2012
Last certification
Jan 5, 2012
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Nov 3, 1999 in MO
Enrollment address
1109 W Clay Rd
Versailles, MO 65084-1177

Other NPIs with the same Medicare PAC ID 6

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

Locations

701 N Oak St
Stover, MO 65078
Phone (573) 377-2217

Ownership & related parties

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.

NameRoleSinceShare
Angela Saran Individual Corporate OfficerBoard Secretary Mar 1, 2016
Corporate DirectorBoard Member Mar 1, 2016
Linda Messenger Individual Corporate OfficerBoard Secretary Mar 1, 2002
Corporate DirectorBoard Member Mar 1, 2002
Michelle Hendricks Individual Corporate OfficerCfo Jan 1, 2024
Michael Waller Individual Corporate OfficerCeo Jan 1, 2024
W-2 Managing EmployeeCeo Jan 1, 2024

Practitioners & affiliated clinicians

Practitioners 50

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 50

NPI Registry JSON

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

{
    "created_epoch": "1316649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708473600000",
    "number": "1053694422",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "821 WESTWOOD DR",
            "city": "SEDALIA",
            "state": "MO",
            "postal_code": "653012102",
            "telephone_number": "660-826-4774",
            "fax_number": "660-826-1300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1109 CLAY RD.",
            "city": "VERSAILLES",
            "state": "MO",
            "postal_code": "65084",
            "telephone_number": "573-378-2351"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REGIONAL HEALTH CARE CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-09-22",
        "last_updated": "2024-02-21",
        "certification_date": "2024-02-21",
        "status": "A",
        "authorized_official_last_name": "WALLER",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "573-378-2351"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Katy Trail - Prairie Hills",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Versailles, MO

Sources for this page

Verify at the official NPI Registry.