NPIMap

Organization Active NPI

Pella Regional Health Center

  • Rural Health Clinic/Center
  • Sully, IA
National Provider Identifier
1104860808
Registry record updated Dec 6, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
630165H Issued in IA
Legal business name
PELLA REGIONAL HEALTH CENTER
Practice address
704 3Rd St
Sully, IA 50251-1016
Phone
(641) 594-3150
Fax
(641) 594-3795
NPI assigned
Jun 15, 2006
Organization subpart
Yes
Parent organization
PELLA REGIONAL HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 6, 2022

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

Authorized official

Name
Robert D Kroese
Title
Ceo
Phone
(641) 628-6604

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 630165H IA Primary

Addresses

Primary practice location

704 3Rd St
Sully, IA 50251-1016

Mailing address

P.O. Box 327
704 3Rd Street,
Sully, IA 50251
Phone (641) 594-3150

Other identifiers 1

IdentifierTypeStateIssuer
0634550MedicaidIA

Other names 1

  • Sully Family Health Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address prhc@direct.pellahealth.kobledirect.com Direct

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050127000760 IA Part A Provider - Rural Health Clinic 9931005873 Practice locations: Sully, IA

Rural health clinic certification: CCN 163455

Legal name
PELLA REGIONAL HEALTH CENTER
Doing business as
SULLY FAMILY HEALTH CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 2, 1996
Last certification
Dec 8, 2022
Ownership / control type
2A
Organization structure
CorporationNon-profit
Incorporated
May 1, 1958 in IA
Enrollment address
704 3Rd St
Sully, IA 50251-0327
Related CCNs
161367

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

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
16D0912905Sully Family Health Center704 Third Street, Sully, IA 50251Certificate of waiverAug 12, 2027

National Provider Directory

National Provider Directory
Tax ID family
Pella HLTH Ctr Med Clin13 organizations share this tax ID, including this one
Part of
Pella HLTH Ctr Med Clin

Other organizations with this tax ID 12

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

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Robert D Kroese Individual Corporate OfficerChief Executive Officer Jan 1, 1993
W-2 Managing EmployeeCeo Jan 1, 1993 100%
Chad Loren Huyser Individual Corporate DirectorBoard Director Feb 1, 2019 9.1%
James M Brandl Individual Corporate DirectorVice President Jan 1, 2018 9.1%
Stephen Ambrose Barnes Individual Corporate DirectorBoard Director Jan 1, 2020 9.1%
Bruce Alan Heifner Individual Corporate DirectorChief Financial Officer Feb 9, 2015
W-2 Managing EmployeeChief Financial Officer Feb 9, 2015
Randall C Stravers Individual Corporate DirectorBoard Chairman Jan 1, 2017 9.1%
Kathleen Ann Thompson Individual Corporate DirectorBoard Director Jul 1, 2022 9%
Michael P Morgan Individual Corporate DirectorBoard Director Jan 1, 2014 9.1%
Mary Lou Glendening Individual Corporate DirectorBoard Secretary Jan 1, 2015 9.1%
Leslie Johnston Individual Corporate DirectorBoard Director Apr 1, 2020 9.1%
Craig Allen Wittenberg Individual Corporate DirectorBoard Member Apr 1, 2002 9.1%
Richard Dale Posthuma Individual Corporate DirectorBoard Director Jul 1, 2019 9.1%
Pella Regional Health Center Organization, Pella, IA Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 1996 100%
Operational/Managerial Control Jan 1, 1996
Travis Turnbull Individual Corporate DirectorBoard Treasurer Sep 1, 2019 9.1%

Owners & managing parties with NPI records 12

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

All facility ownership & control disclosures 6

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

FacilityTypeRoleSince
Pella Regional Health CenterPella, IA, CCN 161367 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 29, 2013
Aug 29, 2013
Pella Regional Health CenterPella, IA, CCN 16Z367 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 29, 2013
Nov 15, 2007
Pella Regional Home Health AgencyPella, IA, CCN 167220 Home health agency 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Nov 21, 2007
Jan 1, 1994
Hospice of Pella, the Comfort HousePella, IA, CCN 161538 Hospice 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 19, 1996
Sep 19, 1996
Ottumwa Medical ClinicOttumwa, IA, CCN 168562 Rural health clinic Operational/Managerial Control (100%) Aug 1, 2012
Prairie City Medical ClinicPrairie City, IA, CCN 168660 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
5% Or Greater Security Interest (100%)
Operational/Managerial Control (100%)		 Jul 1, 2017
Jul 1, 2017
Jul 1, 2017

Owned or controlled facilities with NPI records 6

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 6

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

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": "1150329600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1670284800000",
    "number": "1104860808",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O. BOX 327",
            "address_2": "704 3RD STREET,",
            "city": "SULLY",
            "state": "IA",
            "postal_code": "50251",
            "telephone_number": "641-594-3150",
            "fax_number": "641-594-3795"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "704 3RD ST",
            "city": "SULLY",
            "state": "IA",
            "postal_code": "502511016",
            "telephone_number": "641-594-3150",
            "fax_number": "641-594-3795"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PELLA REGIONAL HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PELLA REGIONAL HEALTH CENTER",
        "enumeration_date": "2006-06-15",
        "last_updated": "2022-12-06",
        "certification_date": "2022-12-06",
        "status": "A",
        "authorized_official_last_name": "KROESE",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "641-628-6604"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "IA",
            "license": "630165H",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0634550",
            "state": "IA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "prhc@direct.pellahealth.kobledirect.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "704 3rd St",
            "city": "Sully",
            "state": "IA",
            "country_code": "US",
            "postal_code": "502511016",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Sully Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sully Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sully, IA

Sources for this page

Verify at the official NPI Registry.