NPIMap

Organization Active NPI

Aaron E. Henry Community Health Services Center, Inc

  • Pediatrics Physician
  • Clarksdale, MS
National Provider Identifier
1134868672
Registry record updated Jun 2, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
AARON E. HENRY COMMUNITY HEALTH SERVICES CENTER, INC
Practice address
2245 N State St
Clarksdale, MS 38614-6102
Phone
(662) 624-4292
Fax
(662) 624-4354
NPI assigned
Jun 2, 2022
Last updated
Jun 2, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
AARON E. HENRY COMMUNITY HEALTH SERVICES CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 2, 2022

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

Authorized official

Name
Candace L Fondren
Title
Revenue Cycle Manager
Phone
(662) 624-4292

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X Primary

Addresses

Primary practice location

2245 N State St
Clarksdale, MS 38614-6102

Mailing address

PO Box 1216
Clarksdale, MS 38614-1216
Phone (662) 624-4292

Other identifiers 1

IdentifierTypeStateIssuer
09010039MedicaidMS

Other names 1

  • The Childrens Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221109001009 MS Part A Provider - Federally Qualified Health Center (FQHC) 1153230560 Practice locations: Clarksdale, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1134868672. Details of each certification follow.

Federally qualified health center certification: CCN 251134

Legal name
AARON E HENRY COMMUNITY HEALTH
Doing business as
CHILDREN'S CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 6, 2022
Last certification
Sep 6, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 10, 1982 in MS
Enrollment address
2245 N State St
Clarksdale, MS 38614-6102

Other NPIs with the same Medicare PAC ID 5

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
25D0678162Children's Clinic, the2245 N State St, Clarksdale, MS 38614Certificate of waiverJul 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Aaron E Henry Community Health18 organizations share this tax ID, including this one
Part of
Aaron E Henry Community Health

Other organizations with this tax ID 17

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

View all 17

Locations

1040 Desoto Ave
Clarksdale, MS 38614
Phone (601) 624-2504

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Aurelia Jones-Taylor Individual 5% Or Greater Direct Ownership InterestCeo Jun 5, 1989 5%
W-2 Managing EmployeeCeo Jun 8, 1989 5%
Josephine Rhymes Individual 5% Or Greater Direct Ownership InterestBoard Vice President Jan 12, 1994 5%
Robert Jackson Individual 5% Or Greater Direct Ownership InterestBoard President May 11, 2004 5%

Practitioners & affiliated clinicians

Practitioners 34

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.

View all 34

NPI Registry JSON

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

{
    "created_epoch": "1654128000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654128000000",
    "number": "1134868672",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1216",
            "city": "CLARKSDALE",
            "state": "MS",
            "postal_code": "386141216",
            "telephone_number": "662-624-4292",
            "fax_number": "662-624-4354"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2245 N STATE ST",
            "city": "CLARKSDALE",
            "state": "MS",
            "postal_code": "386146102",
            "telephone_number": "662-624-4292",
            "fax_number": "662-624-4354"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AARON E. HENRY COMMUNITY HEALTH SERVICES CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "AARON E. HENRY COMMUNITY HEALTH SERVICES CENTER, INC",
        "enumeration_date": "2022-06-02",
        "last_updated": "2022-06-02",
        "certification_date": "2022-06-02",
        "status": "A",
        "authorized_official_last_name": "FONDREN",
        "authorized_official_first_name": "CANDACE",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "REVENUE CYCLE MANAGER",
        "authorized_official_telephone_number": "662-624-4292"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09010039",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Childrens Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Clarksdale, MS

Sources for this page

Verify at the official NPI Registry.