Family Health Care Clinic, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Tylertown, MS
NPI 1376776930 · NPPES record last updated Jul 4, 2018
Key facts
- NPI
- 1376776930
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- FAMILY HEALTH CARE CLINIC, INC.
- Practice address
- 225 Saint Paul Road
Tylertown, MS 39667 - Phone
- (601) 825-7280
- Fax
- (601) 825-8130
- NPI assigned
- Aug 31, 2009
- Organization subpart
- No
Authorized official
- Name
- Karina Marie Clayton
- Title
- Chief Financial Officer
- Phone
- (601) 825-7280
Other NPIs on the same Medicare enrollment 37
Practitioners 2
-
Dennis U Adams, MD
-
Nashamba Jackson-Bracey, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Federally qualified health center certification: CCN 251812
- Legal name
- FAMILY HEALTH CARE CLINIC INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 25, 2009
- Last certification
- Sep 25, 2009
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 1, 1996 in MS
- Enrollment address
- 225 Saint Paul Rd
Tylertown, MS 39667-6163
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Cierra Hernandez |
Corporate Director |
Sep 1, 2022 | |
| Margaret a Gray |
Corporate Director |
Jul 1, 1980 | |
| W-2 Managing Employee |
Jul 1, 1980 | ||
| Kaitlynn Mixon-Smith |
Corporate Officer |
Jan 1, 2019 | |
| Charles Hatten |
Corporate Director |
Jul 21, 2009 | |
| Michael Howard |
Corporate Director |
Jul 21, 2009 | |
| Helen Johnson |
Corporate Director |
Jul 21, 2009 | |
| Louise Patterson |
Corporate Director |
Jul 21, 2009 | |
| Moses Johnson |
Corporate Director |
Feb 1, 2016 | |
| Carolyn Hartzog |
Corporate Director |
Jul 21, 2009 | |
| Lydia Gonzalez-Seals |
Corporate Director |
Feb 1, 2016 | |
| James W Hill |
Corporate Officer |
Jan 1, 2019 | |
| Eddie Thames |
Corporate Director |
Jul 21, 2009 |
All facility ownership & control disclosures 6
| Facility | Type | Role | Since |
|---|---|---|---|
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
| Family Health Care Clinic Inc |
Federally qualified health center | Operational/Managerial Control | Aug 1, 2009 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040831001179 | MS | Part B Supplier - Clinic/Group Practice | 5395656946 |
Receives reassigned benefits from 71 practitioners 37 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Monticello, MS; Pearl, MS; Newhebron, MS; Pelahatchie, MS; Piney Woods, MS; Pinola, MS; Prentiss, MS; Raleigh, MS… |
| O20090917000261 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 5395656946 | Practice locations: Tylertown, MS |
National Provider Directory
Locations
225 Saint Paul Rd
Tylertown, MS 39667
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | MS | Yes |
Addresses
Primary practice location
225 Saint Paul Road
Tylertown, MS 39667
Mailing address
PO Box 24116
Jackson, MS 39225-4116
Phone (601) 825-7280
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00683565 | Medicaid | MS |
Other providers in Tylertown, MS
- Pamela Dillon
- Diversicare of Tylertown, LLC
- Eagle Health Care Services, Inc
- Ashlei Chulette Ellzey
- Essential Care LLC
- Family Health Care Clinic, Inc.
- Family Health Care Clinic, Inc.
- Family Medicine Associates, PA
- Yolanda Fortenberry
- Posavanike S Ganaraj
All providers in Tylertown, MS · Federally Qualified Health Center (FQHC) in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 4, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.