Southern Divine Family Medical Center LLC
Organization Active NPI Internal Medicine Physician · Altoona, AL
NPI 1104456920 · NPPES record last updated Apr 9, 2022
Key facts
- NPI
- 1104456920
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- Legal business name
- SOUTHERN DIVINE FAMILY MEDICAL CENTER LLC
- Practice address
- 7130 6TH Ave
Altoona, AL 35952-9052 - Phone
- (205) 589-1092
- Fax
- (205) 589-1096
- NPI assigned
- Jan 21, 2020
- Organization subpart
- No
Authorized official
- Name
- Enrico D Gaspar, MD
- Title
- Owner
- Phone
- (256) 840-8181
Owners & managing parties with NPI records 1
-
Enrico D Gaspar, M.D.
Practitioners 7
-
Enrico D Gaspar, M.D.
-
Ethan Caleb Bonds, CRNP
-
Ashley Brooke Bozarth, CRNP
-
Cody Jarmon, CRNP
-
Patrick Sellers, CRNP
-
Alvin V Tenchavez, M.D.
-
Amanda McCormick Willis, CRNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 01D2167843 | United Doctors Family Medical Center - Altoona | Certificate of waiver | Jun 16, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in AL
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
- LLC · Proprietary
- Enrollment address
- 7130 6TH St
Altoona, AL 35952-9052
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Enrico Deseo Y. Gaspar |
5% Or Greater Direct Ownership Interest | Dec 11, 2019 | 100% |
| Corporate Officer |
Dec 11, 2019 | 100% | |
| Operational/Managerial Control |
Dec 11, 2019 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20200622002415 | AL | Part B Supplier - Clinic/Group Practice | 0648692582 |
Receives reassigned benefits from 7 practitioners Practice locations: Altoona, AL |
| O20210107001276 | AL | Part a Provider - Rural Health Clinic | 0648692582 | Practice locations: Altoona, AL |
National Provider Directory
Locations
7130 6th Ave
Altoona, AL 35952
Phone (205) 589-1092
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | Yes | ||
| Acute Care Nurse Practitioner |
363LA2100X | |||
| Adult Health Nurse Practitioner |
363LA2200X | |||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
7130 6TH Ave
Altoona, AL 35952-9052
Mailing address
PO Box 35
Altoona, AL 35952-0035
Phone (205) 589-1092
Other names
- United Doctors Family Medical Center - Altoona
Other providers in Altoona, AL
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All providers in Altoona, AL · Internal Medicine Physician in Alabama
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 9, 2022. 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.