NPIMap

Organization Active NPI

Puckett Family Clinic, P.C.

  • Rural Health Clinic/Center
  • Honey Grove, TX
National Provider Identifier
1295937449
Registry record updated Oct 25, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
PA02778 Issued in TX
Legal business name
PUCKETT FAMILY CLINIC, P.C.
Practice address
1301 E Main St
Honey Grove, TX 75446-1268
Phone
(903) 378-3444
NPI assigned
Jun 1, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 25, 2012

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

Authorized official

Name
Mr. Paul Laval Puckett, PA-CNPI 1407961410
Title
Physician Assistant - Certified
Phone
(903) 378-3444

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X PA02778 TX Primary
Medical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AM0700X PA02778 TX

Addresses

Primary practice location

1301 E Main St
Honey Grove, TX 75446-1268

Mailing address

PO Box 166
Honey Grove, TX 75446-0166
Phone (903) 378-3444

Other identifiers 1

IdentifierTypeStateIssuer
PA02778OtherTXSTATE LICENSE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070827000743 TX Part B Supplier - Clinic/Group Practice 6103918735 Receives reassigned benefits from 3 practitioners
Practice locations: Honey Grove, TX
O20111011000093 TX Part A Provider - Rural Health Clinic 6103918735 Practice locations: Honey Grove, TX

Rural health clinic certification: CCN 673919

Legal name
PUCKETT FAMILY CLINIC, P.C.
Doing business as
PUCKETT FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 23, 2012
Last certification
Apr 10, 2018
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
May 22, 2007 in TX
Enrollment address
1301 E Main St
Honey Grove, TX 75446-1268

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
45D1082934Puckett Family Clinic1301 East Main Street, Honey Grove, TX 75446Provider-performed microscopyApr 21, 2028

National Provider Directory

National Provider Directory

Locations

1301 E Main St
Honey Grove, TX 75446
Phone (903) 378-3444

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Melissa Puckett Individual 5% Or Greater Direct Ownership Interest May 22, 2007 49%
Corporate OfficerSecretary May 22, 2007 49%
Corporate DirectorSecretary May 22, 2007 49%
Kyle Elliott Jones Individual Contracted Managing EmployeeMD; Jan 1, 2016 10%
Puckett Family Clinic, P.C. Organization, Honey Grove, TX 5% Or Greater Direct Ownership Interest Sep 30, 2011
Operational/Managerial Control Sep 30, 2011
Paul L Puckett Individual 5% Or Greater Direct Ownership Interest May 22, 2007 51%
Corporate OfficerPresident May 22, 2007 51%
Corporate DirectorPresident May 22, 2007 51%
W-2 Managing EmployeePresident May 22, 2007 51%

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1180656000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1351123200000",
    "number": "1295937449",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 166",
            "city": "HONEY GROVE",
            "state": "TX",
            "postal_code": "754460166",
            "telephone_number": "903-378-3444",
            "fax_number": "903-378-3445"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 E MAIN ST",
            "city": "HONEY GROVE",
            "state": "TX",
            "postal_code": "754461268",
            "telephone_number": "903-378-3444"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUCKETT FAMILY CLINIC, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-01",
        "last_updated": "2012-10-25",
        "status": "A",
        "authorized_official_last_name": "PUCKETT",
        "authorized_official_first_name": "PAUL",
        "authorized_official_middle_name": "LAVAL",
        "authorized_official_title_or_position": "PHYSICIAN ASSISTANT - CERTIFIED",
        "authorized_official_telephone_number": "903-378-3444",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TX",
            "license": "PA02778",
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": "TX",
            "license": "PA02778",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "PA02778",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Honey Grove, TX

Sources for this page

Verify at the official NPI Registry.