NPIMap

Organization Active NPI

Escambia Community Clinics Inc

Doing business as 12th Avenue Pediatrics

  • Federally Qualified Health Center (FQHC)
  • Pensacola, FL
National Provider Identifier
1073842456
Registry record updated Nov 30, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
ESCAMBIA COMMUNITY CLINICS INC
Doing business as
12th Avenue Pediatrics
Practice address
2510 N 12TH Ave
Pensacola, FL 32503
Phone
(850) 471-0508
Fax
(850) 471-0510
NPI assigned
Dec 15, 2009
Last updated
Nov 30, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
ESCAMBIA COMMUNITY CLINICS INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 30, 2018

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

Authorized official

Name
Chandra Smiley, EXECUTIVE DIRECTOR
Title
Executive Director
Phone
(850) 436-4630

Specialties & licenses 1

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

Addresses

Primary practice location

2510 N 12TH Ave
Pensacola, FL 32503

Mailing address

2315 W Jackson St
Pensacola, FL 32505-7552
Phone (850) 436-4630

Other identifiers 1

IdentifierTypeStateIssuer
692990705MedicaidFL

Other names 1

  • 12th Avenue Pediatrics Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120301000914 FL Part A Provider - Federally Qualified Health Center (FQHC) 9638165806 Practice locations: Pensacola, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073842456. Details of each certification follow.

Federally qualified health center certification: CCN 101081

Legal name
ESCAMBIA COMMUNITY CLINICS INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 1, 2012
Last certification
Mar 1, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1990 in FL
Enrollment address
2510 N 12TH Ave
Lanza Pediatrics
Pensacola, FL 32503-4604

Other NPIs with the same Medicare PAC ID 14

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

View all 14

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D1041026Escambia Community Clinics, Inc Dba2510 N 12TH Ave, Pensacola, FL 32503Certificate of waiverMay 23, 2027

National Provider Directory

National Provider Directory
Tax ID family
Escambia Community Clin15 organizations share this tax ID, including this one
Part of
Escambia Community Clin

Other organizations with this tax ID 14

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

View all 14

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
Grace McCaffery Individual Corporate DirectorBoard Member Jul 29, 2021
Bob Wilson Individual Corporate DirectorBoard Member Sep 1, 2007
Freddie Cattouse Individual Corporate DirectorBoard Member Sep 1, 2007
Dorothy Foster Individual Corporate DirectorBoard Member Apr 1, 2017
Ann Osiname Individual Corporate DirectorBoard Member Sep 1, 2007
Walter Ritchie Individual Corporate DirectorBoard Member Sep 1, 2007
Chandra Smiley Individual Corporate OfficerExecutive Director Dec 1, 2014
W-2 Managing EmployeeExecutive Director Dec 1, 2014
Jules Kariher Individual Corporate DirectorVice Chairman Oct 1, 2017
Justin H Labrato Individual Corporate DirectorTreasurer Mar 1, 2014
Joseph Emmanuel Individual Corporate DirectorBoard Mem Sep 1, 2007
Brett Aldridge Individual Corporate DirectorBoard Member Jul 1, 2018
John T Porter Individual Corporate DirectorChairman Sep 1, 2007
Sean Seely Individual Corporate DirectorBoard Member Apr 1, 2017

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Community Health Northwest FloridaPensacola, FL, CCN 681048 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jan 29, 1992
Community Health Northwest FloridaPensacola, FL, CCN 681849 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jan 9, 2023

Owned or controlled facilities with NPI records 2

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

NPI Registry JSON

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

{
    "created_epoch": "1260835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1543536000000",
    "number": "1073842456",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2315 W JACKSON ST",
            "city": "PENSACOLA",
            "state": "FL",
            "postal_code": "325057552",
            "telephone_number": "850-436-4630",
            "fax_number": "850-436-2095"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2510 N 12TH AVE",
            "city": "PENSACOLA",
            "state": "FL",
            "postal_code": "32503",
            "telephone_number": "850-471-0508",
            "fax_number": "850-471-0510"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ESCAMBIA COMMUNITY CLINICS INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESCAMBIA COMMUNITY CLINICS INC",
        "enumeration_date": "2009-12-15",
        "last_updated": "2018-11-30",
        "status": "A",
        "authorized_official_last_name": "SMILEY",
        "authorized_official_first_name": "CHANDRA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "850-436-4630",
        "authorized_official_credential": "EXECUTIVE DIRECTOR"
    },
    "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": "692990705",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "12th Avenue Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pensacola, FL

Sources for this page

Verify at the official NPI Registry.