NPIMap

Organization Active NPI

Holden Family Care, LLC

  • Rural Health Clinic/Center
  • Holden, MO
National Provider Identifier
1205154606
Registry record updated Apr 10, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
076670 Issued in MO
Legal business name
HOLDEN FAMILY CARE, LLC
Practice address
612 E 10TH St
Holden, MO 64040-9421
Phone
(816) 732-6010
Fax
(816) 732-6011
NPI assigned
May 10, 2010
Last updated
Apr 10, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 10, 2015

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

Authorized official

Name
Ms. Carol Jean Jackson
Title
Office Manager
Phone
(816) 732-6010

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 076670 MO Primary
Nurse Practitioner 363L00000X 076670 MO

Addresses

Primary practice location

612 E 10TH St
Holden, MO 64040-9421

Mailing address

612 E 10TH St
Holden, MO 64040-9421
Phone (816) 732-6010

Other identifiers 1

IdentifierTypeStateIssuer
1205154606MedicaidMO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100928001615 MO Part B Supplier - Clinic/Group Practice 7113043001 Receives reassigned benefits from 2 practitioners
Practice locations: Holden, MO
O20101209000237 MO Part A Provider - Rural Health Clinic 7113043001 Practice locations: Holden, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205154606. Details of each certification follow.

Rural health clinic certification: CCN 793811

Legal name
HOLDEN FAMILY CARE LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 13, 2011
Last certification
Sep 24, 2024
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Jan 29, 2010 in MO
Enrollment address
612 E 10TH St
Holden, MO 64040-9421

National Provider Directory

National Provider Directory
Tax ID family
Holden Family Care2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Dorothy L Adams Individual 5% Or Greater Direct Ownership Interest Nov 9, 2010 100%
Carol Jean Jackson Individual W-2 Managing Employee Apr 1, 2012

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 3

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": "1273449600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1428624000000",
    "number": "1205154606",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "612 E 10TH ST",
            "city": "HOLDEN",
            "state": "MO",
            "postal_code": "640409421",
            "telephone_number": "816-732-6010",
            "fax_number": "816-732-6011"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "612 E 10TH ST",
            "city": "HOLDEN",
            "state": "MO",
            "postal_code": "640409421",
            "telephone_number": "816-732-6010",
            "fax_number": "816-732-6011"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOLDEN FAMILY CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-10",
        "last_updated": "2015-04-10",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "CAROL",
        "authorized_official_middle_name": "JEAN",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "816-732-6010",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": "076670",
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "MO",
            "license": "076670",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1205154606",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Holden, MO

Sources for this page

Verify at the official NPI Registry.