NPIMap

Organization Active NPI

Park Duvalle Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Louisville, KY
National Provider Identifier
1245253160
Registry record updated Nov 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
700005 Issued in KY
Legal business name
PARK DUVALLE COMMUNITY HEALTH CENTER, INC.
Practice address
3015 Wilson Ave
Louisville, KY 40211-1969
Phone
(502) 774-4401
Fax
(502) 772-4783
NPI assigned
Jul 25, 2006
Last updated
Nov 2, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 2, 2021

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

Authorized official

Name
Swannie Jett
Title
Ceo
Phone
(502) 774-4401

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 700005 KY Primary

Addresses

Primary practice location

3015 Wilson Ave
Louisville, KY 40211-1969

Mailing address

3015 Wilson Ave
Louisville, KY 40211-1969
Phone (502) 774-4401

Other identifiers 1

IdentifierTypeStateIssuer
31000011MedicaidKY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040302000539 KY Part B Supplier - Clinic/Group Practice 1658268974 Receives reassigned benefits from 32 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Eminence, KY; Louisville, KY; Taylorsville, KY
O20040323000421 KY Part A Provider - Federally Qualified Health Center (FQHC) 1658268974 Practice locations: Louisville, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1245253160. Details of each certification follow.

Federally qualified health center certification: CCN 181801

Legal name
PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Doing business as
THE NEIGHBORHOOD HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Mar 30, 1967 in KY
Enrollment address
3015 Wilson Ave
Louisville, KY 40211-1969

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory

Locations

501 Taylorsville Rd
Taylorsville, KY 40071
Phone (502) 477-2248

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
Darrell L Shaw Individual Corporate DirectorMember Board of Directors Nov 24, 2011
William Holden Individual Corporate DirectorBoard Member Jan 1, 2022
Stacy Sowell Individual Corporate DirectorBoard Member Jan 1, 2022
Desmond L Robinson Individual Corporate DirectorMember Board of Director Aug 21, 2017
Katie Calloway Individual Corporate DirectorMember Board of Directors Aug 21, 2017
Swannie Jett Individual Corporate OfficerCeo Nov 1, 2021
Corporate DirectorCeo Nov 1, 2021
W-2 Managing EmployeeCeo Nov 1, 2021
Operational/Managerial ControlCeo Nov 1, 2021
Barbara Mitchell Individual Corporate Director Dec 1, 2009
Kevin Bruce Individual Corporate DirectorMember Board of Directors Aug 21, 2017
Angela Wilson Individual Corporate DirectorMember Board of Directors Aug 21, 2017
Deborah E Thomas Individual Corporate DirectorMember Board of Directors Sep 24, 2011
Dwayne Compton Individual Corporate DirectorBoard Member Jan 1, 2021
Martin Tucker Individual Corporate Director Dec 1, 2009

Practitioners & affiliated clinicians

Practitioners 46

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.

View all 46

NPI Registry JSON

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

{
    "created_epoch": "1153785600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635811200000",
    "number": "1245253160",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3015 WILSON AVE",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402111969",
            "telephone_number": "502-774-4401",
            "fax_number": "502-772-4783"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3015 WILSON AVE",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402111969",
            "telephone_number": "502-774-4401",
            "fax_number": "502-772-4783"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PARK DUVALLE COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-25",
        "last_updated": "2021-11-02",
        "certification_date": "2021-11-02",
        "status": "A",
        "authorized_official_last_name": "JETT",
        "authorized_official_first_name": "SWANNIE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "502-774-4401"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "KY",
            "license": "700005",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31000011",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Louisville, KY

Sources for this page

Verify at the official NPI Registry.