NPIMap

Organization Active NPI

County of Henry

  • Rural Health Clinic/Center
  • Kewanee, IL
National Provider Identifier
1265066625
Registry record updated Feb 25, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COUNTY OF HENRY
Practice address
110 N Burr Blvd
Kewanee, IL 61443-2214
Phone
(309) 852-0197
Fax
(309) 852-0595
NPI assigned
Feb 25, 2020
Last updated
Feb 25, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
COUNTY OF HENRYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 25, 2020

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

Authorized official

Name
Tara Lafollette
Title
Credentialing Representative
Phone
(309) 852-0197

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

110 N Burr Blvd
Kewanee, IL 61443-2214

Mailing address

110 N Burr Blvd
Kewanee, IL 61443-2214
Phone (309) 852-0197

Other names 1

  • First Choice Healthcare Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190613000110 IL Part A Provider - Rural Health Clinic 5193828556 1 other NPI on this enrollment
Practice locations: Kewanee, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1265066625. Details of each certification follow.

Rural health clinic certification: CCN 783852

Legal name
COUNTY OF HENRY
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 9, 2021
Last certification
Jun 9, 2021
Ownership / control type
Non-profit – church related
Organization structure
GovernmentNon-profit
Enrollment address
110 N Burr Blvd
Kewanee, IL 61443-2214

Other NPIs with the same Medicare PAC ID 2

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

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
Tax ID family
County of Henry3 organizations share this tax ID, including this one
Part of
County of Henry

Other organizations with this tax ID 2

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

Locations

110 N Burr Blvd
Kewanee, IL 61443
Phone (309) 852-0197

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
Kelli Humphrey Individual W-2 Managing Employee Jul 1, 2019
Duane Stevens Individual Corporate DirectorAdministrator Jul 1, 2019
W-2 Managing Employee Jul 1, 2019

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Hillcrest HomeGeneseo, IL, CCN 145949 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
5% Or Greater Security Interest (100%)
Operational/Managerial Control
Adp of the SNF		 Sep 28, 2011
Sep 28, 2011
Sep 28, 2011
Sep 28, 2011

Owned or controlled facilities with NPI records 1

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

  • Hillcrest Home
    • Skilled Nursing Facility
    • Geneseo, IL
    • NPI 1770582330

    5% Or Greater Direct Ownership Interest, 5% Or Greater Security Interest, Adp of the SNF, Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 2

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": "1582588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582588800000",
    "number": "1265066625",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "110 N BURR BLVD",
            "city": "KEWANEE",
            "state": "IL",
            "postal_code": "614432214",
            "telephone_number": "309-852-0197",
            "fax_number": "309-852-0595"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "110 N BURR BLVD",
            "city": "KEWANEE",
            "state": "IL",
            "postal_code": "614432214",
            "telephone_number": "309-852-0197",
            "fax_number": "309-852-0595"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTY OF HENRY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COUNTY OF HENRY",
        "enumeration_date": "2020-02-25",
        "last_updated": "2020-02-25",
        "certification_date": "2020-02-25",
        "status": "A",
        "authorized_official_last_name": "LAFOLLETTE",
        "authorized_official_first_name": "TARA",
        "authorized_official_title_or_position": "CREDENTIALING REPRESENTATIVE",
        "authorized_official_telephone_number": "309-852-0197"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "First Choice Healthcare",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Kewanee, IL

Sources for this page

Verify at the official NPI Registry.