Southern Divine Family Medical Center LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

SOUTHERN DIVINE FAMILY MEDICAL CENTER LLC

Doing business as

United Doctors Family Medical Center - Altoona

Practice address

7130 6TH Ave
Altoona, AL 35952-9052

Phone

(205) 589-1092

Fax

(205) 589-1096

NPI assigned

Jan 21, 2020

Last updated

Apr 9, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Enrico D Gaspar, MDNPI 1497740492

Title

Owner

Phone

(256) 840-8181

Specialties & licenses 4

Addresses

Other names 1

• United Doctors Family Medical Center - Altoona Doing business as

Medicare fee-for-service enrollment

Enrolled in AL2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104456920. Details of each certification follow.

• CCN 018954 Rural health clinic · Active · Details

Rural health clinic certification: CCN 018954

Legal name

SOUTHERN DIVINE FAMILY MEDICAL CENTER LLC

Doing business as

UNITED DOCTORS FAMILY MEDICAL CENTER- ALTOONA

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Jun 9, 2021

Last certification

Jun 9, 2021

Ownership / control type

1A

Organization structure

LLCProprietary

Enrollment address

7130 6TH St
Altoona, AL 35952-9052

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

CLIA laboratory certificates

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.

Owners & managing parties with NPI records 1

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

• Enrico D Gaspar, M.D.

  • Internal Medicine Physician
  • Boaz, AL
  • NPI 1497740492

  5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control

  CMS ownership

Practitioners 7

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.

• Enrico D Gaspar, M.D.

  • Internal Medicine Physician
  • Boaz, AL
  • NPI 1497740492
  Medicare reassignment Care Compare group NPD Authorized official
• Ethan Caleb Bonds, CRNP

  • Family Nurse Practitioner
  • Boaz, AL
  • NPI 1154082758
  Medicare reassignment Care Compare group NPD
• Ashley Brooke Bozarth, CRNP

  • Internal Medicine Physician
  • Altoona, AL
  • NPI 1184439184
  Medicare reassignment Care Compare group NPD
• Cody Jarmon, CRNP

  • Acute Care Nurse Practitioner
  • Boaz, AL
  • NPI 1497230478
  Medicare reassignment Care Compare group NPD
• Patrick Sellers, CRNP

  • Family Nurse Practitioner
  • Boaz, AL
  • NPI 1205342268
  Medicare reassignment Care Compare group NPD
• Alvin V Tenchavez, M.D.

  • Internal Medicine Physician
  • Boaz, AL
  • NPI 1225023211
  Medicare reassignment NPD
• Amanda McCormick Willis, CRNP

  • Family Nurse Practitioner
  • Altoona, AL
  • NPI 1508559956
  Medicare reassignment NPD

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

{
    "created_epoch": "1579564800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649462400000",
    "number": "1104456920",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 35",
            "city": "ALTOONA",
            "state": "AL",
            "postal_code": "359520035",
            "telephone_number": "205-589-1092",
            "fax_number": "205-589-1096"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7130 6TH AVE",
            "city": "ALTOONA",
            "state": "AL",
            "postal_code": "359529052",
            "telephone_number": "205-589-1092",
            "fax_number": "205-589-1096"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN DIVINE FAMILY MEDICAL CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-21",
        "last_updated": "2022-04-09",
        "certification_date": "2022-04-09",
        "status": "A",
        "authorized_official_last_name": "GASPAR",
        "authorized_official_first_name": "ENRICO",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "256-840-8181",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LA2100X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Acute Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "United Doctors Family Medical Center - Altoona",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• John Morgan Gentry, RPH
• Jamie Grant
• Klein Drug Shoppe, Inc
• Heather Laughlin, COTA
• Jeffery H Mooneyham, CRNP
• Perry L Swann, MD
• Angie Vaughan, RPH
• Kyndal Sanford Washburn
• Amanda McCormick Willis, CRNP
• Kasey Hawkins Wilson, MSN, FNP-C

• Internal Medicine Physician in Altoona, AL
• Providers in Altoona, AL by specialty
• Internal Medicine Physician in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.