NPIMap

Organization Active NPI

Family Health Care Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Duck Hill, MS
National Provider Identifier
1154554251
Registry record updated Apr 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FAMILY HEALTH CARE CLINIC, INC.
Practice address
620 Carrollton St
Duck Hill, MS 38925
Phone
(601) 825-7280
Fax
(601) 825-8130
NPI assigned
Aug 24, 2009
Last updated
Apr 16, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 16, 2020

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

Authorized official

Name
Karina Marie Clayton
Title
Chief Financial Officer
Phone
(601) 825-7280

Specialties & licenses 1

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

Addresses

Primary practice location

620 Carrollton St
Duck Hill, MS 38925

Mailing address

PO Box 24116
Jackson, MS 39225-4116
Phone (601) 825-7280

Other identifiers 1

IdentifierTypeStateIssuer
08572361MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040831001179 MS Part B Supplier - Clinic/Group Practice 5395656946 Receives reassigned benefits from 71 practitioners
37 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Monticello, MS; Pearl, MS; Newhebron, MS; Pelahatchie, MS; Piney Woods, MS; Pinola, MS; Prentiss, MS; Raleigh, MS…
O20090924000392 MS Part A Provider - Federally Qualified Health Center (FQHC) 5395656946 Practice locations: Duck Hill, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154554251. Details of each certification follow.

Federally qualified health center certification: CCN 251984

Legal name
FAMILY HEALTH CARE CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 30, 2009
Last certification
Sep 30, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1996 in MS
Enrollment address
620 Carrollton St
Duck Hill, MS 38925-9416

Other NPIs on the same Medicare enrollment 37

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

View all 37

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
25D2032516Family Health Care Clinic Inc620 Carrollton Avenue, Duck Hill, MS 38925Certificate of waiverNov 8, 2027

National Provider Directory

National Provider Directory
Tax ID family
Family Health Care Clinic Inc36 organizations share this tax ID, including this one

Other organizations with this tax ID 35

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

View all 35

Locations

620 Carrollton St
Duck Hill, MS 38925

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Brenda Blakeslee Individual Corporate DirectorBoard Member Sep 1, 2022
Cierra Hernandez Individual Corporate DirectorBoard Member Sep 1, 2022
Margaret a Gray Individual Corporate DirectorPresident and Ceo Jul 21, 2009
W-2 Managing EmployeePresident and Ceo Jul 21, 2009
Charles Hatten Individual Corporate DirectorBoard Member Aug 28, 2009
Michael Howard Individual Corporate DirectorBoard Member-Treasurer Aug 19, 2009
Helen Johnson Individual Corporate DirectorBoard Member-Secretary Aug 19, 2009
Louise Patterson Individual Corporate DirectorBoard Member-Chair Aug 19, 2009
Moses Johnson Individual Corporate DirectorBoard Member-Vice Chair Feb 1, 2014
Carolyn Hartzog Individual Corporate DirectorDirector Aug 28, 2009
Lydia Gonzalez-Seals Individual Corporate DirectorBoard Member-Officer Feb 1, 2014
Cindy Bryan Individual Corporate DirectorBoard Member Aug 19, 2009
Eddie Thames Individual Corporate DirectorBoard Member Aug 19, 2009

All facility ownership & control disclosures 6

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

FacilityTypeRoleSince
Family Health Care Clinic IncRussellville, AL, CCN 011965 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncMuscle Shoals, AL, CCN 011970 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncDecatur, AL, CCN 011967 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncTown Creek, AL, CCN 011966 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncFlorence, AL, CCN 011969 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncRogersville, AL, CCN 011971 Federally qualified health center Operational/Managerial Control Aug 1, 2009

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": "1251072000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1586995200000",
    "number": "1154554251",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 24116",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392254116",
            "telephone_number": "601-825-7280",
            "fax_number": "601-825-8130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "620 CARROLLTON ST",
            "city": "DUCK HILL",
            "state": "MS",
            "postal_code": "38925",
            "telephone_number": "601-825-7280",
            "fax_number": "601-825-8130"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY HEALTH CARE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-24",
        "last_updated": "2020-04-16",
        "certification_date": "2020-04-16",
        "status": "A",
        "authorized_official_last_name": "CLAYTON",
        "authorized_official_first_name": "KARINA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "601-825-7280"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "08572361",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Duck Hill, MS

Sources for this page

Verify at the official NPI Registry.