NPIMap

Organization Active NPI

Audubon Area Community Care Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Owensboro, KY
National Provider Identifier
1114462272
Registry record updated Oct 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
AUDUBON AREA COMMUNITY CARE CLINIC, INC.
Practice address
4215 Benttree Dr
Owensboro, KY 42301-8669
Phone
(270) 686-6040
Fax
(270) 686-6050
NPI assigned
Dec 28, 2016
Last updated
Oct 15, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
AUDUBON AREA COMMUNITY SERVICES, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 15, 2024

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

Authorized official

Name
Samantha Taylor Kaai
Title
Clinic Program Director
Phone
(270) 686-6040

Specialties & licenses 1

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

Addresses

Primary practice location

4215 Benttree Dr
Owensboro, KY 42301-8669

Mailing address

PO Box 1874
Owensboro, KY 42302-1874
Phone (270) 686-6040

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170613001089 KY Part A Provider - Federally Qualified Health Center (FQHC) 3678841822 Practice locations: Owensboro, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114462272. Details of each certification follow.

Federally qualified health center certification: CCN 181021

Legal name
AUDUBON AREA COMMUNITY CARE CLINIC, INC.
Organization structure
CorporationProprietary
Incorporated
May 10, 2016 in KY
Enrollment address
750 Salem Dr
Ste 2
Owensboro, KY 42303-7758

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
18D2131660Audubon Area Community Care Clinic4215 Benttree Dr, Owensboro, KY 42301Certificate of waiverJun 4, 2027

National Provider Directory

National Provider Directory
Tax ID family
Audubon Area Community Care Clinic Inc12 organizations share this tax ID, including this one
Part of
Audubon Area Community Services Inc

Other organizations with this tax ID 11

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

Locations

4215 Benttree Dr
Owensboro, KY 42301
Phone (270) 315-0001

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Michael Johnson Individual Corporate DirectorTreasurer Oct 1, 2019 0.2%
Scott Pulliam Individual Corporate DirectorBoard Member Oct 1, 2019 0.2%
Christy Bartley Individual Corporate DirectorSecretary Jan 1, 2020 0.2%
Susan Montalvo-Gesser Individual Corporate DirectorVice President Apr 1, 2020 0.2%
Ashley Holderby Individual Corporate DirectorBoard Member Apr 1, 2022 0.2%
Audubon Area Community Services, Inc. Organization, Owensboro, KY Non-profit Operational/Managerial Control Jul 13, 2016 100%
Robert Jones Individual Corporate OfficerChief Executive Officer Mar 3, 2017
Operational/Managerial ControlChief Executive Officer Mar 3, 2017 100%
Austin Blaine Mathew Individual Corporate DirectorBoard Member May 1, 2022 0.2%
Mary T Danhauer Individual Corporate DirectorBoard Member Apr 1, 2021 0.2%
Joseph Welsh Individual Corporate DirectorBoard Member Jan 1, 2019 0.2%
Cheryl Moore Individual Corporate DirectorPresident Apr 1, 2020 0.2%
Samantha Taylor-Kaai Individual Operational/Managerial ControlProject Director Aug 5, 2019 100%
Jeffrey Berry Individual Corporate DirectorBoard Member Jan 1, 2019 0.2%
Karla Ward Individual Corporate DirectorBoard Member Apr 1, 2022 0.2%
Byron Mayes Individual Corporate OfficerChief Financial Officer Mar 3, 2017
Patrick S Rykwalder Individual Corporate DirectorBoard Member Jun 1, 2021 0.2%
Brandon Harley Individual Corporate OfficerDeputy Ceo Mar 3, 2017
Harry Pedigo Individual Corporate DirectorBoard Member Mar 3, 2017 0.2%

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

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.

NPI Registry JSON

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

{
    "created_epoch": "1482883200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728950400000",
    "number": "1114462272",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1874",
            "city": "OWENSBORO",
            "state": "KY",
            "postal_code": "423021874",
            "telephone_number": "270-686-6040",
            "fax_number": "270-686-6050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4215 BENTTREE DR",
            "city": "OWENSBORO",
            "state": "KY",
            "postal_code": "423018669",
            "telephone_number": "270-686-6040",
            "fax_number": "270-686-6050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AUDUBON AREA COMMUNITY CARE CLINIC, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "AUDUBON AREA COMMUNITY SERVICES, INC.",
        "enumeration_date": "2016-12-28",
        "last_updated": "2024-10-15",
        "certification_date": "2024-10-15",
        "status": "A",
        "authorized_official_last_name": "KAAI",
        "authorized_official_first_name": "SAMANTHA",
        "authorized_official_middle_name": "TAYLOR",
        "authorized_official_title_or_position": "CLINIC PROGRAM DIRECTOR",
        "authorized_official_telephone_number": "270-686-6040"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Owensboro, KY

Sources for this page

Verify at the official NPI Registry.