NPIMap

Organization Active NPI

Kidz 1St Clinic, LLC

  • Rural Health Clinic/Center
  • Yazoo City, MS
National Provider Identifier
1083265284
Registry record updated May 31, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
KIDZ 1ST CLINIC, LLC
Practice address
321 E Fifteenth St
Yazoo City, MS 39194-2631
Phone
(662) 532-1543
NPI assigned
Sep 27, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 31, 2022

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

Authorized official

Name
Tiffany Allison Bowen, CPNP-PC
Title
Owner
Phone
(662) 532-1543

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Pediatric Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LP0200X

Addresses

Primary practice location

321 E Fifteenth St
Yazoo City, MS 39194-2631

Mailing address

321 E Fifteenth St
Yazoo City, MS 39194-2631
Phone (662) 532-1543

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200408001207 MS Part A Provider - Rural Health Clinic 6103253570 Practice locations: Yazoo City, MS

Rural health clinic certification: CCN A53801

Legal name
KIDZ 1ST CLINIC LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 14, 2020
Last certification
Aug 14, 2020
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Sep 23, 2019 in MS
Enrollment address
321 E Fifteenth St
Yazoo City, MS 39194-2631

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
25D2179429Kidz 1St Clinic LLC321 E Fifteenth St, Yazoo City, MS 39194Certificate of waiverFeb 23, 2028

National Provider Directory

National Provider Directory

Locations

321 E Fifteenth St
Yazoo City, MS 39194
Phone (662) 532-1543

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Tiffany Allison Bowen Individual 5% Or Greater Direct Ownership InterestOwner Sep 23, 2019 100%
W-2 Managing Employee0Wner Jan 1, 2020 100%

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 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1569542400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1653955200000",
    "number": "1083265284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "321 E FIFTEENTH ST",
            "city": "YAZOO CITY",
            "state": "MS",
            "postal_code": "391942631",
            "telephone_number": "662-532-1543",
            "fax_number": "662-532-1544"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "321 E FIFTEENTH ST",
            "city": "YAZOO CITY",
            "state": "MS",
            "postal_code": "391942631",
            "telephone_number": "662-532-1543"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KIDZ 1ST CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-27",
        "last_updated": "2022-05-31",
        "certification_date": "2022-05-31",
        "status": "A",
        "authorized_official_last_name": "BOWEN",
        "authorized_official_first_name": "TIFFANY",
        "authorized_official_middle_name": "ALLISON",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "662-532-1543",
        "authorized_official_credential": "CPNP-PC"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Yazoo City, MS

Sources for this page

Verify at the official NPI Registry.