NPIMap

Organization Active NPI

Fast Pace Medical Clinic PLLC

  • Rural Health Clinic/Center
  • Centerville, AL
National Provider Identifier
1336804772
Registry record updated Mar 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
FAST PACE MEDICAL CLINIC PLLC
Practice address
998 2ND Ave E.
Centerville, AL 35121-2506
Phone
(205) 395-5014
NPI assigned
Nov 1, 2021
Last updated
Mar 27, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 27, 2024

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

Authorized official

Name
Sydni Clemmons
Title
Credentialing Manager
Phone
(901) 351-1791

Specialties & licenses 1

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

Addresses

Primary practice location

998 2ND Ave E.
Centerville, AL 35121-2506

Mailing address

PO Box 306244
Nashville, TN 37230-6244

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN, AL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20211123002779 TN Part A Provider - Rural Health Clinic 5395881841 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Centerville, TN
O20240416004251 AL Part A Provider - Rural Health Clinic 5395881841 Practice locations: Oneonta, AL

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1336804772. Details of each certification follow.

Rural health clinic certification: CCN 883867

Legal name
FAST PACE MEDICAL CLINIC PLLC
Doing business as
FAST PACE HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 21, 2022
Last certification
Jan 21, 2022
Ownership / control type
1A
Organization structure
OtherProprietary
Incorporated
Oct 5, 2009 in TN
Enrollment address
1140 Highway 100
Centerville, TN 37033-1139

Rural health clinic certification: CCN 018978

Legal name
FAST PACE MEDICAL CLINIC PLLC
Doing business as
FAST PACE HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 14, 2024
Last certification
Aug 14, 2024
Ownership / control type
1B
Organization structure
OtherProprietary
Incorporated
Aug 10, 2020 in AL
Enrollment address
998 2ND Ave E
Oneonta, AL 35121-2506

Other NPIs with the same Medicare PAC ID 14

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

View all 14

Other NPIs on the same Medicare enrollment 1

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

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
01D2304698Fast Pace Medical Clinic, PLLC998 2ND Ave E, Oneonta, AL 35121Certificate of waiverMay 15, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Selena Michelle Gurley Individual 5% Or Greater Direct Ownership Interest Oct 5, 2019 33.33%
5% Or Greater Direct Ownership InterestOwner Oct 5, 2019 33.33%
Fpmcm, LLC Organization, Franklin, TN LLC Operational/Managerial Control Oct 5, 2009 100%
Sydni Clemmons Individual Corporate DirectorDirector of Credentialing Nov 1, 2021
W-2 Managing Employee Nov 1, 2021
Karen Denise Daingerfield Individual 5% Or Greater Direct Ownership Interest Oct 5, 2019 33.33%
5% Or Greater Direct Ownership InterestOwner Oct 5, 2019 33.33%
Dana Kay Martin Individual 5% Or Greater Direct Ownership Interest Oct 5, 2019 33.33%
5% Or Greater Direct Ownership InterestOwnership Oct 5, 2019 33.33%
Melissa Harlan Individual W-2 Managing EmployeeDirector of Credentialing Jul 8, 2024
Christy Littlejohn Individual W-2 Managing EmployeeCred Manager Jul 8, 2024

Owners & managing parties with NPI records 3

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

NPI Registry JSON

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

{
    "created_epoch": "1635724800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711497600000",
    "number": "1336804772",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 306244",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372306244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "998 2ND AVE E.",
            "city": "CENTERVILLE",
            "state": "AL",
            "postal_code": "351212506",
            "telephone_number": "205-395-5014"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAST PACE MEDICAL CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-01",
        "last_updated": "2024-03-27",
        "certification_date": "2024-03-25",
        "status": "A",
        "authorized_official_last_name": "CLEMMONS",
        "authorized_official_first_name": "SYDNI",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "901-351-1791"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Sources for this page

Verify at the official NPI Registry.