NPIMap

Organization Active NPI

Independent Healthcare Management, Inc.

Doing business as Lackey Pediatric Clinic

  • Rural Health Clinic/Center
  • Forest, MS
National Provider Identifier
1154670719
Registry record updated May 26, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Doing business as
Lackey Pediatric Clinic
Practice address
1129 Highway 35 S
Suite 1
Forest, MS 39074-8829
Phone
(601) 849-6440
Fax
(601) 849-1318
NPI assigned
Aug 29, 2012
Last updated
May 26, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2020

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

Authorized official

Name
John P Lee
Title
Chairman of the Board
Phone
(601) 849-6440

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 13-033 MS
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

1129 Highway 35 S
Suite 1
Forest, MS 39074-8829

Mailing address

1129 Highway 35 S
Suite 1
Forest, MS 39074-8829
Phone (601) 849-6440

Other identifiers 1

IdentifierTypeStateIssuer
13033OtherMSLICENSE

Other names 1

  • Lackey Pediatric Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031215000487 MS Part B Supplier - Clinic/Group Practice 0840197232 Receives reassigned benefits from 95 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Raleigh, MS; Newton, MS; Morton, MS; Magee, MS; Forest, MS
O20150709000047 MS Part A Provider - Rural Health Clinic 0840197232 Practice locations: Forest, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154670719. Details of each certification follow.

Rural health clinic certification: CCN 258608

Legal name
INDEPENDENT HEALTHCARE MANAGEMENT INC
Doing business as
LACKEY PEDIATRIC CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 9, 2015
Last certification
Aug 19, 2022
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Dec 5, 2012 in MS
Enrollment address
1 Medical LN
Forest, MS 39074-4039
Related CCNs
251300

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

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 13

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

View all 13

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
25D2048983Lackey Pediatric Clinic1 Medical Lane, Forest, MS 39074Certificate of waiverOct 25, 2026

National Provider Directory

National Provider Directory
Tax ID family
Bruce Hospital ER15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

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

View all 14

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
John P Lee Individual Corporate OfficerChairman of the Board Jan 1, 2018 100%
Corporate DirectorChairman of the Board Jan 1, 2018 100%
Operational/Managerial ControlChairman of the Board Jan 1, 2018 100%
Independent Healthcare Management Inc Organization, Forest, MS Non-profit, Chain home office Operational/Managerial Control Jan 1, 2018 100%
Sydney Sawyer Individual Corporate OfficerAdministrator Jan 1, 2019 100%
Corporate DirectorAdministrator Jan 1, 2019 100%
Operational/Managerial ControlAdministrator Jan 1, 2019 100%

Owners & managing parties with NPI records 9

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

All facility ownership & control disclosures 8

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

FacilityTypeRoleSince
SE Lackey Memorial HospitalForest, MS, CCN 251300 Hospital 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 2019
Jan 1, 2019
Independent Healthcare Management IncForest, MS, CCN 25M300 Hospital 5% Or Greater Direct Ownership Interest (100%) May 23, 2007
SE Lackey Memorial HospitalForest, MS, CCN 25Z300 Hospital 5% Or Greater Direct Ownership Interest (100%) May 23, 2007
Community Health ClinicForest, MS, CCN 258504 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Aug 14, 1989
Main Street Medical Clinic of MortonMorton, MS, CCN 258570 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 9, 2015
Sep 9, 2015
Newton Family and Pediatric ClinicNewton, MS, CCN 258617 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 14, 1989
Aug 14, 1989
Independent Healthcare Management IncMagee, MS, CCN 258653 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 1, 2020
Sep 1, 2020
Independent Healthcare Management IncRaleigh, MS, CCN 258684 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jul 17, 2023
Jul 1, 2023

Owned or controlled facilities with NPI records 8

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

Facilities with the same owner 8

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

Practitioners & affiliated clinicians

Practitioners 9

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": "1346198400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1590451200000",
    "number": "1154670719",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1129 HIGHWAY 35 S",
            "address_2": "SUITE 1",
            "city": "FOREST",
            "state": "MS",
            "postal_code": "390748829",
            "telephone_number": "601-849-6440",
            "fax_number": "601-849-1318"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1129 HIGHWAY 35 S",
            "address_2": "SUITE 1",
            "city": "FOREST",
            "state": "MS",
            "postal_code": "390748829",
            "telephone_number": "601-849-6440",
            "fax_number": "601-849-1318"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDEPENDENT HEALTHCARE MANAGEMENT, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-08-29",
        "last_updated": "2020-05-26",
        "certification_date": "2020-05-26",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "CHAIRMAN OF THE BOARD",
        "authorized_official_telephone_number": "601-849-6440"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "MS",
            "license": "13-033",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "13033",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lackey Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lackey Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Forest, MS

Sources for this page

Verify at the official NPI Registry.