Active NPI
Infinity Health
- Federally Qualified Health Center (FQHC)
- Princeton, MO
National Provider Identifier
1366949877
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Federally Qualified Health Center (FQHC)
- Legal business name
- INFINITY HEALTH
- Practice address
- 606 W Main St
Princeton, MO 64673-1140 - Phone
- (660) 748-3022
- Fax
- (515) 608-4592
- NPI assigned
- Apr 11, 2018
- Last updated
- Feb 11, 2022
- Organization subpart
- Yes
- Parent organization
- INFINITY HEALTH
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Samantha Cannon
- Title
- Ceo
- Phone
- (641) 446-2383
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Primary |
Addresses
Primary practice location
606 W Main St
Princeton, MO 64673-1140
Mailing address
302 NE 14TH St
Leon, IA 50144-1206
Phone (641) 446-2383
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0462887 | Medicaid | IA | |
| 507202208 | Medicaid | MO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MO
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20180802000408 | MO | Part A Provider - Federally Qualified Health Center (FQHC) | 5597717496 | Practice locations: Princeton, MO |
| O20200601000739 | MO | Part B Supplier - Clinic/Group Practice | 5597717496 |
Receives reassigned benefits from 1 practitioner 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Princeton, MO |
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1366949877. Details of each certification follow.
Federally qualified health center certification: CCN 261160
- Legal name
- INFINITY HEALTH
- Doing business as
- COMMUNITY HEALTH CENTERS OF SOUTHERN IOWA INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Aug 1, 2018
- Last certification
- Aug 1, 2018
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation
- Incorporated
- Jan 17, 1997 in IA
- Enrollment address
- 606 W Main St
Princeton, MO 64673-1140
Other NPIs with the same Medicare PAC ID 11
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
-
dba Behavioral Health Centers of SO IA - Centerville
- Federally Qualified Health Center (FQHC)
- Centerville, IA
- NPI 1710102132
5597717496
-
dba Community Health Centers of Southern Iowa, Inc
- Federally Qualified Health Center (FQHC)
- Knoxville, IA
- NPI 1790364875
5597717496
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- Part of
- Infinity Health - Archived
Ownership & related parties
All disclosed owners & managing parties 11
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Justin James Akers | Corporate Director | Aug 22, 2017 | 10% |
| Rachel Cecil | Corporate Director | Mar 26, 2019 | 10% |
| Shirley Kessel | Corporate Director | Jan 1, 2005 | 10% |
| Jonathan Erb | Corporate Director | Sep 24, 2019 | 10% |
| Alan Wilson | Corporate Director | Mar 23, 2010 | 10% |
| William Morain | Corporate Director | Jan 1, 2005 | 10% |
| Marcy Biesemeyer | Corporate Director | Apr 22, 2014 | 10% |
| Dien Judge | Corporate Director | Oct 28, 2014 | 10% |
| Kyle E Ahlenstorf | Corporate Officer | Dec 27, 2023 | |
| Corporate Director | Dec 27, 2023 | ||
| W-2 Managing Employee | Dec 27, 2023 | ||
| Linda Baynes | Corporate Director | May 22, 2018 | 10% |
| Alan Dykens | Corporate Director | Jan 24, 2017 | 10% |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1523404800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1644537600000",
"number": "1366949877",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "302 NE 14TH ST",
"city": "LEON",
"state": "IA",
"postal_code": "501441206",
"telephone_number": "641-446-2383"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "606 W MAIN ST",
"city": "PRINCETON",
"state": "MO",
"postal_code": "646731140",
"telephone_number": "660-748-3022",
"fax_number": "515-608-4592"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "INFINITY HEALTH",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "INFINITY HEALTH",
"enumeration_date": "2018-04-11",
"last_updated": "2022-02-11",
"certification_date": "2022-02-11",
"status": "A",
"authorized_official_last_name": "CANNON",
"authorized_official_first_name": "SAMANTHA",
"authorized_official_title_or_position": "CEO",
"authorized_official_telephone_number": "641-446-2383"
},
"taxonomies": [
{
"code": "261QF0400X",
"taxonomy_group": "",
"desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0462887",
"state": "IA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "507202208",
"state": "MO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Princeton, MO
- Mary Katherine Easter, CPO, OTR/L
- Lauren Renee Guilkey, PLPC
- Tammy K. Hart, M.D.
- Carol Lynn Hubbard
- Hy-Vee Inc (Hy-Vee Clinic Pharmacy (1036))
- Amy Lee McDaniel, MS PT
- Medley Pharmacy Inc (EverCare Pharmacy LTC)
- Medley Pharmacy Inc. (EverCare Pharmacy)
- Mercer County Ambulance District
- Mercer County Ambulance District
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.