NPIMap

Organization Active NPI

Family Health Care Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Water Valley, MS
National Provider Identifier
1083087985
Registry record updated Apr 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Apr 16, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 16, 2020

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

Authorized official

Name
Karina Marie Clayton
Title
Chief Financial Officer
Phone
(601) 825-7280

Specialties & licenses 1

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

Addresses

Primary practice location

102 Blackmur Dr
Water Valley, MS 38965

Mailing address

PO Box 24116
Jackson, MS 39225-4116
Phone (601) 825-7280

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083087985. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Jun 1, 1996 in MS
Enrollment address
102 Blackmur Dr
Water Valley, MS 38965-3003

Other NPIs on the same Medicare enrollment 37

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

View all 37

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
25D2105090Family Health Care Clinic Inc-Water Valley102 Blackmur Drive, Water Valley, MS 38965Provider-performed microscopyNov 16, 2027

National Provider Directory

National Provider Directory
Tax ID family
Family Health Care Clin36 organizations share this tax ID, including this one

Other organizations with this tax ID 35

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

View all 35

Locations

102 Blackmur Dr
Water Valley, MS 38965
Phone (662) 473-2547

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
Brenda Blakeslee Individual Corporate Officer Sep 1, 2022
Cierra Hernandez Individual Corporate Officer Sep 1, 2022
Margaret a Gray Individual Corporate DirectorDirector/President May 20, 2013
W-2 Managing EmployeePresident/Ceo May 20, 2013
Charles Hatten Individual Corporate Officer Nov 25, 2014
Michael Howard Individual Corporate Officer Nov 25, 2014
Helen Johnson Individual Corporate Officer Sep 1, 2022
Louise Patterson Individual Corporate Officer Nov 25, 2014
Moses Johnson Individual Corporate Officer Nov 25, 2014
Carolyn Hartzog Individual Corporate Officer Sep 1, 2022
Lydia Gonzalez-Seals Individual Corporate Officer Nov 25, 2014
Cindy Bryan Individual Corporate Officer Nov 25, 2014
Eddie Thames Individual Corporate Officer Nov 25, 2014

All facility ownership & control disclosures 6

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

FacilityTypeRoleSince
Family Health Care Clinic IncRussellville, AL, CCN 011965 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncMuscle Shoals, AL, CCN 011970 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncDecatur, AL, CCN 011967 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncTown Creek, AL, CCN 011966 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncFlorence, AL, CCN 011969 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncRogersville, AL, CCN 011971 Federally qualified health center Operational/Managerial Control Aug 1, 2009

Practitioners & affiliated clinicians

Practitioners 1

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": "1446422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1586995200000",
    "number": "1083087985",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 24116",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392254116",
            "telephone_number": "601-825-7280",
            "fax_number": "601-825-8130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 BLACKMUR DR",
            "city": "WATER VALLEY",
            "state": "MS",
            "postal_code": "38965",
            "telephone_number": "662-473-2547"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY HEALTH CARE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-02",
        "last_updated": "2020-04-16",
        "certification_date": "2020-04-16",
        "status": "A",
        "authorized_official_last_name": "CLAYTON",
        "authorized_official_first_name": "KARINA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "601-825-7280"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Water Valley, MS

Sources for this page

Verify at the official NPI Registry.