NPIMap

Organization Active NPI

Community Health Center of Northeast Oklahoma, Inc.

Doing business as CHCNEO Jay Family Medicine Clinic

  • Federally Qualified Health Center (FQHC)
  • Jay, OK
National Provider Identifier
1114519774
Registry record updated Feb 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA, INC.
Doing business as
CHCNEO Jay Family Medicine Clinic
Practice address
2485 N. Main St.
Jay, OK 74346
Phone
(918) 253-2550
Fax
(918) 253-2122
NPI assigned
Feb 5, 2021
Last updated
Feb 5, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 5, 2021

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

Authorized official

Name
Janet Mendez
Title
Ceo
Phone
(918) 257-8029

Specialties & licenses 1

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

Addresses

Primary practice location

2485 N. Main St.
Jay, OK 74346

Mailing address

P.O. Box 705
Afton, OK 74331-0705
Phone (918) 257-8029

Other names 1

  • CHCNEO Jay Family Medicine Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140610000303 OK Part B Supplier - Clinic/Group Practice 9133352081 Receives reassigned benefits from 12 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Afton, OK; Commerce, OK; Jay, OK; Vinita, OK; Welch, OK
O20210317001977 OK Part A Provider - Federally Qualified Health Center (FQHC) 9133352081 Practice locations: Jay, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114519774. Details of each certification follow.

Federally qualified health center certification: CCN 371963

Legal name
COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA, INC
Doing business as
CHCNEO JAY FAMILY MEDICINE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 16, 2021
Last certification
Mar 16, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 16, 2010 in OK
Enrollment address
2485 N Main St
Jay, OK 74346-2201

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Community Health Center of3 organizations share this tax ID, including this one
Part of
Community Health Center of

Other organizations with this tax ID 2

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

Locations

2485 N Main St
Ste 2201
Jay, OK 74346

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Community Health Center of Northeast Oklahoma, Inc Organization, Afton, OK Corporation, Non-profit Operational/Managerial Control Jan 1, 2021 100%
Janet Mendez Individual Corporate OfficerCeo Jan 1, 2021 100%
Operational/Managerial ControlCeo Jan 1, 2021 100%

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Route 66 Health ClinicAfton, OK, CCN 371892 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Sep 16, 2010
Route 66 Health ClinicWelch, OK, CCN 371930 Federally qualified health center Operational/Managerial Control (100%) Oct 1, 2019
Allensworth Community Health CenterVinita, OK, CCN 371940 Federally qualified health center Operational/Managerial Control (100%) Feb 11, 2019

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

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

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": "1612483200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612483200000",
    "number": "1114519774",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O. BOX 705",
            "city": "AFTON",
            "state": "OK",
            "postal_code": "743310705",
            "telephone_number": "918-257-8029",
            "fax_number": "918-257-8042"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2485 N. MAIN ST.",
            "city": "JAY",
            "state": "OK",
            "postal_code": "74346",
            "telephone_number": "918-253-2550",
            "fax_number": "918-253-2122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY HEALTH CENTER OF NORTHEAST OKLAHOMA, INC.",
        "enumeration_date": "2021-02-05",
        "last_updated": "2021-02-05",
        "certification_date": "2021-02-05",
        "status": "A",
        "authorized_official_last_name": "MENDEZ",
        "authorized_official_first_name": "JANET",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "918-257-8029"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CHCNEO Jay Family Medicine Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jay, OK

Sources for this page

Verify at the official NPI Registry.