NPIMap

Organization Active NPI

Mountain Comprehensive Care Center, Inc.

Doing business as Homeplace Clinic Prestonsburg

  • Federally Qualified Health Center (FQHC)
  • Prestonsburg, KY
National Provider Identifier
1336989292
Registry record updated May 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Doing business as
Homeplace Clinic Prestonsburg
Practice address
456 S Lake Dr
Prestonsburg, KY 41653-1298
Phone
(606) 886-4346
NPI assigned
May 29, 2024
Last updated
May 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 2024

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

Authorized official

Name
Roxann Cordial
Title
Credentialing Manager
Phone
(606) 886-8572

Specialties & licenses 1

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

Addresses

Primary practice location

456 S Lake Dr
Prestonsburg, KY 41653-1298

Mailing address

104 S Front Ave
Prestonsburg, KY 41653-1614
Phone (606) 886-8572

Other names 1

  • Homeplace Clinic Prestonsburg Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040416000380 KY Part B Supplier - Clinic/Group Practice 5294720553 Receives reassigned benefits from 237 practitioners
24 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Paintsville, KY; Pikeville, KY; Prestonsburg, KY; Salyersville, KY; Winchester, KY; Martin, KY; Ashland, KY; Belfry, KY…
O20241101003039 KY Part A Provider - Federally Qualified Health Center (FQHC) 5294720553 Practice locations: Prestonsburg, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1336989292. Details of each certification follow.

Federally qualified health center certification: CCN B01146

Legal name
MOUNTAIN COMPREHENSIVE CARE CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 4, 2024
Last certification
Oct 4, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 17, 1966 in KY
Enrollment address
456 S Lake Dr
Prestonsburg, KY 41653-1298

Other NPIs with the same Medicare PAC ID 24

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

View all 24

Other NPIs on the same Medicare enrollment 24

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

View all 24

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
18D2305149Mountain Comprehensive Care Center, Inc -456 South Lake Drive, Prestonsburg, KY 41653Certificate of waiverMay 27, 2028

National Provider Directory

National Provider Directory
Tax ID family
Mt Comprehensive Care C48 organizations share this tax ID, including this one

Other organizations with this tax ID 47

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

View all 47

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
Jim Vanover Individual Corporate DirectorBoard Member Jan 1, 2016
Sara Daniels Individual Corporate DirectorBoard Member Jan 1, 2014
Ancil W Lewis Individual Corporate DirectorBoard Member Jan 1, 2017
Lynette Schindler Individual Corporate DirectorBoard Member Jan 1, 2017
Jackie Tackett Individual Corporate DirectorBoard Member Jan 1, 2017
Durward E Hale Individual Corporate DirectorBoard Member Jan 1, 2017
Charles Branham Individual Corporate DirectorBoard Member Jan 1, 2019
Paula Thompson Individual Corporate DirectorBoard Member Jan 1, 2014
Teresa Petot Individual Corporate DirectorBoard Member Jan 1, 2017
Shirley Ratcliff Individual Corporate DirectorBoard Member Jan 1, 2015
Amanda Looney Individual W-2 Managing EmployeeFinancial Manager Dec 6, 2025
Promod Bishnoi Individual Corporate OfficerCeo Jul 31, 2008
Corporate DirectorCeo Jul 31, 2008

Practitioners & affiliated clinicians

Practitioners 3

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": "1716940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1716940800000",
    "number": "1336989292",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 S FRONT AVE",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416531614",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "456 S LAKE DR",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416531298",
            "telephone_number": "606-886-4346"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN COMPREHENSIVE CARE CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-05-29",
        "last_updated": "2024-05-29",
        "certification_date": "2024-05-29",
        "status": "A",
        "authorized_official_last_name": "CORDIAL",
        "authorized_official_first_name": "ROXANN",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "606-886-8572"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Homeplace Clinic Prestonsburg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Prestonsburg, KY

Sources for this page

Verify at the official NPI Registry.