NPIMap

Organization Active NPI

Lake Village Clinic PA

  • Rural Health Clinic/Center
  • Lake Village, AR
National Provider Identifier
1306801212
Registry record updated Sep 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
MC0189 Issued in AR
Legal business name
LAKE VILLAGE CLINIC PA
Practice address
2918 Louis Sessions St
Lake Village, AR 71653-6049
Phone
(870) 265-5343
Fax
(870) 265-5686
NPI assigned
Apr 20, 2006
Last updated
Sep 27, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 27, 2024

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

Authorized official

Name
Suzanne Howell
Title
Billing Manager
Phone
(870) 265-5343

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X MC0189 AR
Rural Health Clinic/Center 261QR1300X MC0189 AR Primary

Addresses

Primary practice location

2918 Louis Sessions St
Lake Village, AR 71653-6049

Mailing address

2918 Louis Sessions St
Lake Village, AR 71653-6049
Phone (870) 265-5343

Other identifiers 2

IdentifierTypeStateIssuer
101409002MedicaidAR
127181729MedicaidAR

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050601001036 AR Part B Supplier - Clinic/Group Practice 3274575162 Receives reassigned benefits from 8 practitioners
Practice locations: Lake Village, AR

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
04D0693694Lake Village Clinic2918 Louis Sessions Street, Lake Village, AR 71653Certificate of waiverAug 7, 2027

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/HCCAAA

Ownership & related parties

Change-of-ownership history 1

DateEventCounterparty
Mar 22, 2026 Change of OwnershipThis provider was the seller Lake Village ClinicCCN 048564, AR, NPI 1821953092

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Practitioners 9

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": "1145491200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727395200000",
    "number": "1306801212",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2918 LOUIS SESSIONS ST",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536049",
            "telephone_number": "870-265-5343",
            "fax_number": "870-265-5686"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2918 LOUIS SESSIONS ST",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536049",
            "telephone_number": "870-265-5343",
            "fax_number": "870-265-5686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE VILLAGE CLINIC PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-20",
        "last_updated": "2024-09-27",
        "certification_date": "2024-09-27",
        "status": "A",
        "authorized_official_last_name": "HOWELL",
        "authorized_official_first_name": "SUZANNE",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "870-265-5343"
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": "AR",
            "license": "MC0189",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "AR",
            "license": "MC0189",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "101409002",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "127181729",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Village, AR

Sources for this page

Verify at the official NPI Registry.