NPIMap

Organization Active NPI

Lee County Cooperative Clinic

Doing business as Lakeview Satellite Clinic

  • Federally Qualified Health Center (FQHC)
  • Wabash, AR
National Provider Identifier
1356359442
Registry record updated Mar 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LEE COUNTY COOPERATIVE CLINIC
Doing business as
Lakeview Satellite Clinic
Practice address
14264 Highway 44
Wabash, AR 72389
Phone
(870) 295-5225
Fax
(870) 295-6900
NPI assigned
Aug 4, 2006
Last updated
Mar 2, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 2, 2021

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

Authorized official

Name
Miss Ossie M Hall
Title
Cashier/Billing Supervisor
Phone
(870) 295-5225

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

14264 Highway 44
Wabash, AR 72389

Mailing address

PO Box 669
Marianna, AR 72360-0669
Phone (870) 295-5225

Other identifiers 1

IdentifierTypeStateIssuer
125274749MedicaidAR

Other names 1

  • LAKEVIEW SATELLITE 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
O20081213000190 AR Part B Supplier - Clinic/Group Practice 8921917204 Receives reassigned benefits from 9 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Marianna, AR; Wabash, AR; Madison, AR; Hughes, AR
O20100818001076 AR Part A Provider - Federally Qualified Health Center (FQHC) 8921917204 Practice locations: Wabash, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356359442. Details of each certification follow.

Federally qualified health center certification: CCN 041803

Legal name
LEE COUNTY COOPERATIVE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 17, 1970 in AR
Enrollment address
14066 Hwy 44
Wabash, AR 72389-0035
Related CCNs
041802

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

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory

Locations

530 Atkins Blvd
Marianna, AR 72360

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
Thomas Williams Individual Corporate Director Jan 1, 2021
Cameshia Rogers Individual Corporate OfficerFinance Director Jun 3, 2019
W-2 Managing EmployeeFinance Director Jun 3, 2019
Lois Johnson Individual Corporate Director Jan 1, 2021
Kim Brown Individual W-2 Managing Employee Aug 18, 2020
Summer Long Individual Corporate Director Jan 1, 2021
Charlet Jones Individual Corporate Director Jul 8, 2014
Carrie Carroll Individual Corporate Director Jun 1, 2021
Desi Sims Individual Corporate Director Jan 8, 2019
Quincy Scott Individual Corporate Director Jan 1, 2021
Angela Moore Individual Corporate Director Jan 1, 2021
Kellee Farris Individual Corporate OfficerCeo Sep 28, 2018
Virgie Lee Phillips Individual Corporate Director Sep 28, 2018

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": "1154649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614643200000",
    "number": "1356359442",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 669",
            "city": "MARIANNA",
            "state": "AR",
            "postal_code": "723600669",
            "telephone_number": "870-295-5225",
            "fax_number": "870-295-6900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14264 HIGHWAY 44",
            "city": "WABASH",
            "state": "AR",
            "postal_code": "72389",
            "telephone_number": "870-295-5225",
            "fax_number": "870-295-6900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEE COUNTY COOPERATIVE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-04",
        "last_updated": "2021-03-02",
        "certification_date": "2021-03-02",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "OSSIE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CASHIER/BILLING SUPERVISOR",
        "authorized_official_telephone_number": "870-295-5225",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "125274749",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LAKEVIEW SATELLITE CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "LAKEVIEW SATELLITE CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Sources for this page

Verify at the official NPI Registry.