Family Health Care Clinic, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Water Valley, MS
NPI 1083087985 · NPPES record last updated Apr 16, 2020
Key facts
- NPI
- 1083087985
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- FAMILY HEALTH CARE CLINIC, INC.
- Practice address
- 102 Blackmur Dr
Water Valley, MS 38965 - Phone
- (662) 473-2547
- NPI assigned
- Nov 2, 2015
- Organization subpart
- No
Authorized official
- Name
- Karina Marie Clayton
- Title
- Chief Financial Officer
- Phone
- (601) 825-7280
Other NPIs on the same Medicare enrollment 37
Corporate family (same tax ID) 35
Practitioners 1
-
Joe A Ward, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D2105090 | Family Health Care Clinic Inc-Water Valley | Provider-performed microscopy | Nov 16, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Federally qualified health center certification: CCN 251034
- Legal name
- FAMILY HEALTH CARE CLINIC INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 21, 2016
- Last certification
- Jan 21, 2016
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 1, 1996 in MS
- Enrollment address
- 102 Blackmur Dr
Water Valley, MS 38965-3003
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Brenda Blakeslee |
Corporate Officer | Sep 1, 2022 | |
| Cierra Hernandez |
Corporate Officer | Sep 1, 2022 | |
| Margaret a Gray |
Corporate Director |
May 20, 2013 | |
| W-2 Managing Employee |
May 20, 2013 | ||
| Charles Hatten |
Corporate Officer | Nov 25, 2014 | |
| Michael Howard |
Corporate Officer | Nov 25, 2014 | |
| Helen Johnson |
Corporate Officer | Sep 1, 2022 | |
| Louise Patterson |
Corporate Officer | Nov 25, 2014 | |
| Moses Johnson |
Corporate Officer | Nov 25, 2014 | |
| Carolyn Hartzog |
Corporate Officer | Sep 1, 2022 | |
| Lydia Gonzalez-Seals |
Corporate Officer | Nov 25, 2014 | |
| Cindy Bryan |
Corporate Officer | Nov 25, 2014 | |
| Eddie Thames |
Corporate Officer | Nov 25, 2014 |
All facility ownership & control disclosures 6
| Facility | Type | Role | Since |
|---|---|---|---|
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040831001179 | MS | Part B Supplier - Clinic/Group Practice | 5395656946 |
Receives reassigned benefits from 71 practitioners 37 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Monticello, MS; Pearl, MS; Newhebron, MS; Pelahatchie, MS; Piney Woods, MS; Pinola, MS; Prentiss, MS; Raleigh, MS… |
| O20160121001626 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 5395656946 | Practice locations: Water Valley, MS |
National Provider Directory
- Tax ID family
- Family Health Care Clin
Locations
102 Blackmur Dr
Water Valley, MS 38965
Phone (662) 473-2547
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | MS | Yes |
Addresses
Primary practice location
102 Blackmur Dr
Water Valley, MS 38965
Mailing address
PO Box 24116
Jackson, MS 39225-4116
Phone (601) 825-7280
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 08784312 | Medicaid | MS |
Other providers in Water Valley, MS
- Hunter Edwards
- Stephen Patrick Edwards
- Taylor Watkins Edwards
- Evernorth Direct Health LLC
- Evernorth Direct Health LLC
- Family Practice Clinic of Water Valley
- Family Practice Clinic of Water Valley
- Taylor Robertson Faulkner
- Cody Elizabeth Field
- Jessica Fortner
All providers in Water Valley, MS · Federally Qualified Health Center (FQHC) in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 16, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.