NPIMap

Organization Active NPI

Board of Governors of Dallas County Medical Center

Doing business as Dallas County Medical Center Family Clinic

  • Rural Health Clinic/Center
  • Fordyce, AR
National Provider Identifier
1346378528
Registry record updated Aug 12, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
AR4115 Issued in AR
Legal business name
BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Doing business as
Dallas County Medical Center Family Clinic
Practice address
201 North Clifton Street
Fordyce, AR 71742
Phone
(870) 352-6363
Fax
(870) 352-6343
NPI assigned
Mar 1, 2007
Last updated
Aug 12, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 12, 2016

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

Authorized official

Name
Tamara K Rieves
Title
Administrator / Ceo
Phone
(870) 352-6363

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X AR4115 AR Primary

Addresses

Primary practice location

201 North Clifton Street
Fordyce, AR 71742

Mailing address

201 North Clifton Street
Fordyce, AR 71742
Phone (870) 352-6363

Other identifiers 1

IdentifierTypeStateIssuer
148217105MedicaidAR

Other names 1

  • Dallas County Medical Center Family Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070309000177 AR Part A Provider - Rural Health Clinic 7416869300 Practice locations: Fordyce, AR
O20180221000855 AR Part A Provider - Rural Health Clinic 7416869300 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fordyce, AR

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1346378528. Details of each certification follow.

Rural health clinic certification: CCN 043494

Legal name
BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Doing business as
DALLAS COUNTY MEDICAL CENTER FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 18, 2007
Last certification
Oct 20, 2020
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Incorporated
Sep 13, 2002 in AR
Enrollment address
201 North Clifton Street
Dallas County Medical Center Family Clinic
Fordyce, AR 71742-3026
Related CCNs
041317

Rural health clinic certification: CCN 048515

Legal name
BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Doing business as
NUTT-WALLEY CLINIC OF DALLAS COUNTY MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 1, 2018
Last certification
Jul 27, 2018
Ownership / control type
2B
Organization structure
OtherNon-profit
Incorporated
Sep 13, 2002 in AR
Enrollment address
110 N Clifton St
Fordyce, AR 71742-3065
Related CCNs
041317

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

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
Dallas County Medical C5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

207 N Clifton St
Fordyce, AR 71742
Phone (870) 352-6311

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Kevin Kauffman Individual Corporate Director Mar 19, 2013
Corporate Officer Mar 1, 2018
John Daniel Individual Corporate Director May 14, 2007
Corporate Officer Mar 1, 2018
Christopher K McDaniel Individual Corporate DirectorClinic Director Nov 1, 2018
B D Hargett Individual Corporate Director May 14, 2007
Corporate Officer Mar 1, 2018
Thomas Denton Individual Corporate OfficerCeo May 1, 2026
Corporate DirectorCeo May 1, 2026
W-2 Managing EmployeeCeo May 1, 2026
Don Harris Individual Corporate Director May 14, 2007
Corporate Officer Mar 1, 2018
Dallas County Organization, Fordyce, AR 5% Or Greater Direct Ownership Interest Sep 13, 2002
Duane Brewer Individual Corporate Director May 27, 2015
Corporate Officer Mar 1, 2018
Board of Governors of Dallas County Medical Center Organization, Fordyce, AR 5% Or Greater Direct Ownership Interest Mar 1, 2018 100%

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Nutt-Walley Clinic of Dallas County Medical CenterFordyce, AR, CCN 048515 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2018

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 14

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.

View all 14

NPI Registry JSON

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

{
    "created_epoch": "1172707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1470960000000",
    "number": "1346378528",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 NORTH CLIFTON STREET",
            "city": "FORDYCE",
            "state": "AR",
            "postal_code": "71742",
            "telephone_number": "870-352-6363",
            "fax_number": "870-352-6343"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 NORTH CLIFTON STREET",
            "city": "FORDYCE",
            "state": "AR",
            "postal_code": "71742",
            "telephone_number": "870-352-6363",
            "fax_number": "870-352-6343"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-01",
        "last_updated": "2016-08-12",
        "status": "A",
        "authorized_official_last_name": "RIEVES",
        "authorized_official_first_name": "TAMARA",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "ADMINISTRATOR / CEO",
        "authorized_official_telephone_number": "870-352-6363"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "AR",
            "license": "AR4115",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "148217105",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dallas County Medical Center Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fordyce, AR

Sources for this page

Verify at the official NPI Registry.