NPIMap

Organization Active NPI

Jack County Hospital District

Doing business as faith community hospital amb surg

  • Ambulatory Surgical Clinic/Center
  • Jacksboro, TX
National Provider Identifier
1154419612
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
License
119874903 Issued in TX
Legal business name
JACK COUNTY HOSPITAL DISTRICT
Doing business as
faith community hospital amb surg
Practice address
215 Chisholm TRL
Jacksboro, TX 76458-1403
Phone
(940) 567-6633
Fax
(940) 567-2895
NPI assigned
Oct 10, 2006
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

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

Authorized official

Name
Ms. Kim Lee
Title
Coo
Phone
(940) 567-6633

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X 119874903 TX Primary

Addresses

Primary practice location

215 Chisholm TRL
Jacksboro, TX 76458-1403

Mailing address

215 Chisholm TRL
Jacksboro, TX 76458-1403
Phone (940) 567-6633

Other identifiers 1

IdentifierTypeStateIssuer
119874903MedicaidTX

Other names 1

  • faith community hospital amb surg Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100827000915 TX Part A Provider - Hospital 5890768675 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bowie, TX; Jacksboro, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154419612. Details of each certification follow.

Hospital certification: CCN 450241

Legal name
JACK COUNTY HOSPITAL DISTRICT
Doing business as
FAITH COMMUNITY HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Apr 20, 2022
Beds
41
Ownership / control type
Hospital district or authority
Organization structure
GovernmentNon-profit
Enrollment address
215 Chisholm Trail
Jacksboro, TX 76458-1403
Other Hospital Practice Location
Hospital subgroups
General, Acute care

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

Other NPIs on the same Medicare enrollment 1

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Faith Community HospitalCCN 450241 · All quality measures
Type
Acute Care Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Member organizations 6

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
James Hammond Individual Corporate DirectorBoard Member Jan 1, 2015
Mark Maples Individual Corporate Director Aug 25, 2010
Lori McBrayer Individual Corporate DirectorBoard President Jan 1, 2015
Leslie Chalmers Individual Corporate DirectorEdc Director Jan 1, 2020
Larry Hopwood Individual Corporate DirectorBoard Member Jan 1, 2015
Jack County Hospital District Organization, Jacksboro, TX Operational/Managerial Control Aug 25, 2010
Kim Lee Individual Corporate DirectorChief Financial Officer Oct 1, 2024
Frank L Beaman Individual Corporate DirectorCeo Sep 27, 2012
W-2 Managing Employee Jan 20, 2011
Trina D Johnson Individual W-2 Managing EmployeeFinancial Analyst Oct 1, 2024

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Affiliated clinicians 74

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 74

NPI Registry JSON

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

{
    "created_epoch": "1160438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1154419612",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "215 CHISHOLM TRL",
            "city": "JACKSBORO",
            "state": "TX",
            "postal_code": "764581403",
            "telephone_number": "940-567-6633",
            "fax_number": "940-567-2895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "215 CHISHOLM TRL",
            "city": "JACKSBORO",
            "state": "TX",
            "postal_code": "764581403",
            "telephone_number": "940-567-6633",
            "fax_number": "940-567-2895"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACK COUNTY HOSPITAL DISTRICT",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-10",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "KIM",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "940-567-6633",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "TX",
            "license": "119874903",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "119874903",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "faith community hospital amb surg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksboro, TX

Sources for this page

Verify at the official NPI Registry.