NPIMap

Organization Active NPI

Great Mines Health Center

  • Federally Qualified Health Center (FQHC)
  • Leadwood, MO
National Provider Identifier
1124693510
Registry record updated May 26, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
GREAT MINES HEALTH CENTER
Practice address
1124 Main St RM Nb103
Leadwood, MO 63653-1214
Phone
(573) 438-9535
NPI assigned
May 26, 2021
Last updated
May 26, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2021

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

Authorized official

Name
Gregory A RoebackNPI 1033683354
Title
Ceo
Phone
(573) 438-8359

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

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

Addresses

Primary practice location

1124 Main St RM Nb103
Leadwood, MO 63653-1214

Mailing address

PO Box 761
Potosi, MO 63664-0761
Phone (573) 438-9355

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220705000104 MO Part A Provider - Federally Qualified Health Center (FQHC) 3072598143 Practice locations: Leadwood, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124693510. Details of each certification follow.

Federally qualified health center certification: CCN 261804

Legal name
GREAT MINES HEALTH CENTER
Doing business as
WEST COUNTY SCHOOL SUPERINTENDENT OFFICE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 1, 2022
Last certification
Aug 1, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationProprietary
Incorporated
Oct 7, 2002 in MO
Enrollment address
1124 Main St
RM Nb103
Leadwood, MO 63653-1214

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Great Mines Health Center22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

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

View all 21

Locations

1124 Main St
Rm NB103
Leadwood, MO 63653
Phone (573) 438-9535

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Melanie Schwalenberg Individual Corporate OfficerMember, Board of Directors Jul 26, 2021
Ashleigh Finch Individual Corporate OfficerSecretary, Board of Directors Aug 24, 2020
Keri Smith Individual Corporate OfficerPresident, Board of Directors Aug 27, 2020
Mike G Doty Individual Corporate OfficerMember, Board of Directors Aug 23, 2021
Gregory a Roeback Individual Corporate OfficerCeo Mar 13, 2017
W-2 Managing EmployeeCeo Mar 13, 2017
Angella King Individual Corporate OfficerMember, Board of Directors Aug 23, 2021
Laura Kirkley Individual Corporate OfficerTreasurer, Board of Directors May 24, 2021
Emily Regenold Individual Corporate OfficerMember, Board of Directors Sep 21, 2021
Lee Patterson Individual Corporate OfficerMember, Board of Directors Sep 21, 2021
Linda Dickerson Bell Individual Corporate OfficerVice-President, Board of Directors Jan 22, 2020

Practitioners & affiliated clinicians

Practitioners 1

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": "1621987200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621987200000",
    "number": "1124693510",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 761",
            "city": "POTOSI",
            "state": "MO",
            "postal_code": "636640761",
            "telephone_number": "573-438-9355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1124 MAIN ST RM NB103",
            "city": "LEADWOOD",
            "state": "MO",
            "postal_code": "636531214",
            "telephone_number": "573-438-9535"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT MINES HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-26",
        "last_updated": "2021-05-26",
        "certification_date": "2021-05-14",
        "status": "A",
        "authorized_official_last_name": "ROEBACK",
        "authorized_official_first_name": "GREGORY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "573-438-8359"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Leadwood, MO

Sources for this page

Verify at the official NPI Registry.