NPIMap

Organization Active NPI

Community Health Centers, Inc.

Doing business as 72nd Street Medical Clinic

  • Federally Qualified Health Center (FQHC)
  • Midvale, UT
National Provider Identifier
1073611364
Registry record updated Oct 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH CENTERS, INC.
Doing business as
72nd Street Medical Clinic
Practice address
220 W 7200 S
Suite a
Midvale, UT 84047-1043
Phone
(801) 566-5494
Fax
(877) 497-4661
NPI assigned
Sep 20, 2006
Last updated
Oct 30, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2023

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

Authorized official

Name
Jennifer Lyn Thomas
Title
Executive Director
Phone
(801) 412-6920

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Multi-Specialty Clinic/Center 261QM1300X NU
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU
Family Medicine Physician 207Q00000X NU
Obstetrics & Gynecology Physician 207V00000X NU
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

220 W 7200 S
Suite a
Midvale, UT 84047-1043

Mailing address

1455 W 2200 S Ste 300
West Valley City, UT 84119-7219
Phone (801) 412-6920

Other identifiers 1

IdentifierTypeStateIssuer
1073611364MedicaidUT

Other names 1

  • 72nd Street Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040203000767 UT Part B Supplier - Clinic/Group Practice 5991698169 Receives reassigned benefits from 66 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: West Valley City, UT; Tremonton, UT; Taylorsville, UT; Salt Lake City, UT; Midvale, UT; Brigham City, UT
O20100515000133 UT Part A Provider - Federally Qualified Health Center (FQHC) 5991698169 Practice locations: Midvale, UT

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073611364. Details of each certification follow.

Federally qualified health center certification: CCN 461808

Legal name
COMMUNITY HEALTH CENTERS INC
Doing business as
72ND STREET MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1986 in UT
Enrollment address
220 W 7200 S
Ste a
Midvale, UT 84047-1043

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 8

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

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/ACFCAA

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Laura John Individual W-2 Managing EmployeeCredentialing Specialist Jul 5, 2022
Deanna Long-Smith Individual Corporate DirectorBoard of Governor Apr 22, 2022
Linda Stearns Individual Corporate DirectorBoard of Governor Nov 14, 2016
Lilli E Decair Individual Corporate DirectorBoard of Governor Oct 24, 2013
Jennifer Thomas Individual Corporate OfficerExecutive Director Jun 24, 2022 100%
W-2 Managing EmployeeExecutive Director Jun 24, 2022 100%
Operational/Managerial ControlExecutive Director Jun 24, 2022 100%
Rachel L Hooley Individual Corporate DirectorBoard Secretary Aug 23, 2012
Susan C Johnston Individual Corporate DirectorBoard Secretary Jul 29, 2010
Aline Ashton Individual Corporate DirectorBoard of Governor Oct 28, 2021
Sheila M Hassett Individual Corporate DirectorBoard of Governor Feb 26, 2015
Shawn D Brooks Individual Corporate DirectorBoard of Governor Mar 26, 2020
Gerry Ann Marty Individual Corporate DirectorBoard of Governor Sep 23, 2010
William Henrick Nelson Individual Corporate DirectorBoard President Dec 18, 2014
Robert L Bunnell Individual Corporate OfficerBoard President Aug 23, 2012

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 66

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 66

NPI Registry JSON

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698624000000",
    "number": "1073611364",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1455 W 2200 S STE 300",
            "city": "WEST VALLEY CITY",
            "state": "UT",
            "postal_code": "841197219",
            "telephone_number": "801-412-6920",
            "fax_number": "877-497-4661"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "220 W 7200 S",
            "address_2": "SUITE A",
            "city": "MIDVALE",
            "state": "UT",
            "postal_code": "840471043",
            "telephone_number": "801-566-5494",
            "fax_number": "877-497-4661"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-20",
        "last_updated": "2023-10-30",
        "certification_date": "2023-10-30",
        "status": "A",
        "authorized_official_last_name": "THOMAS",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "LYN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "801-412-6920"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1073611364",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "72nd Street Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Midvale, UT

Sources for this page

Verify at the official NPI Registry.