NPIMap

Organization Active NPI

Fast Pace Medical Clinic PLLC

  • Multi-Specialty Clinic/Center
  • Lincoln, AL
National Provider Identifier
1154791812
Registry record updated Oct 5, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
FAST PACE MEDICAL CLINIC PLLC
Practice address
25 Bear Pkwy
Lincoln, AL 35096-6798
Phone
(205) 548-4106
NPI assigned
Oct 6, 2015
Last updated
Oct 5, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 5, 2022

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

Authorized official

Name
Sydni Clemmons
Title
Credentialing Manager
Phone
(931) 253-1110

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X Primary

Addresses

Primary practice location

25 Bear Pkwy
Lincoln, AL 35096-6798

Mailing address

PO Box 306244
Nashville, TN 37230-6244

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211130000985 TN Part A Provider - Rural Health Clinic 5395881841 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Waverly, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154791812. Details of each certification follow.

Rural health clinic certification: CCN 883884

Legal name
FAST PACE MEDICAL CLINIC PLLC
Doing business as
FAST PACE HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 21, 2022
Last certification
Jan 21, 2022
Ownership / control type
1A
Organization structure
OtherProprietary
Incorporated
Oct 5, 2009 in TN
Enrollment address
301 W Main St
Waverly, TN 37185-1512

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Selena Michelle Gurley Individual 5% Or Greater Direct Ownership Interest May 1, 2019 33.33%
Fpmcm, LLC Organization, Franklin, TN LLC Operational/Managerial Control Oct 5, 2009 100%
Sydni Clemmons Individual Corporate DirectorDirector of Credentialing Nov 1, 2021
W-2 Managing Employee Nov 11, 2021
Karen Denise Daingerfield Individual 5% Or Greater Direct Ownership Interest May 1, 2019 33.33%
Dana Kay Martin Individual 5% Or Greater Direct Ownership Interest May 1, 2019 33.33%

Owners & managing parties with NPI records 3

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

NPI Registry JSON

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

{
    "created_epoch": "1444089600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1664928000000",
    "number": "1154791812",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 306244",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372306244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25 BEAR PKWY",
            "city": "LINCOLN",
            "state": "AL",
            "postal_code": "350966798",
            "telephone_number": "205-548-4106"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAST PACE MEDICAL CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-06",
        "last_updated": "2022-10-05",
        "certification_date": "2022-10-05",
        "status": "A",
        "authorized_official_last_name": "CLEMMONS",
        "authorized_official_first_name": "SYDNI",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "931-253-1110"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lincoln, AL

Sources for this page

Verify at the official NPI Registry.