NPIMap

Organization Active NPI

Pendleton Community Care Inc

  • Federally Qualified Health Center (FQHC)
  • Circleville, WV
National Provider Identifier
1386051035
Registry record updated Jun 14, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PENDLETON COMMUNITY CARE INC
Practice address
1 School Lane
Circleville, WV 26804-0187
Phone
(304) 567-3193
NPI assigned
Jul 15, 2014
Last updated
Jun 14, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 14, 2016

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

Authorized official

Name
Jaime Hudson
Title
Ceo
Phone
(304) 358-2355

Specialties & licenses 1

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

Addresses

Primary practice location

1 School Lane
Circleville, WV 26804-0187

Mailing address

PO Box 100
Franklin, WV 26807-0100
Phone (304) 358-2355

Other names 1

  • North Fork Elementary School SBHC Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20141205000954 WV Part A Provider - Federally Qualified Health Center (FQHC) 3678470614 Practice locations: Circleville, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386051035. Details of each certification follow.

Federally qualified health center certification: CCN 511058

Legal name
PENDLETON COMMUNITY CARE INC
Doing business as
NORTH FORK ELEMENTARY SCHOOL - SCHOOL BASED HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 23, 2014
Last certification
Oct 23, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 27, 1982 in WV
Enrollment address
189 Price Way
Circleville, WV 26804-0187

Other NPIs with the same Medicare PAC ID 8

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

National Provider Directory

National Provider Directory
Tax ID family
Pendleton Community Car10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

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

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Mary Cassell Individual Corporate DirectorBoard Vice-Chairman Aug 1, 2000
Robert Davis Individual Corporate Director Mar 3, 2016
Janice Heavner Individual Corporate Director Jan 7, 2016
Jamie Hudson Individual Corporate OfficerCeo Jun 1, 2016
W-2 Managing EmployeeCeo Jun 1, 2016
Michelle Sites Individual Corporate Director Apr 6, 2017
Joseph D Bucher Individual Corporate DirectorBoard Member Jan 1, 2014
Nancy Bowers Individual Corporate DirectorBoard Secretary May 1, 2007
Pendleton Community Care Inc Organization, Franklin, WV Non-profit 5% Or Greater Direct Ownership Interest Jul 15, 2014 100%
Melissa Grimes Individual Corporate Director Aug 5, 2021
Peggy Davis Individual Corporate DirectorBoard Member Jan 1, 2001
Eugene McConnell Individual Corporate DirectorBoard Chairman Oct 1, 2008
Larry Thomas Individual Corporate DirectorBoard Member Jan 1, 2010
Isaac Sponaugle Individual Corporate DirectorBoard Member Apr 3, 2014
Rebecca Lynn Eason Individual Corporate OfficerCfo Jun 1, 2016
W-2 Managing EmployeeCfo Jun 1, 2016

Owners & managing parties with NPI records 8

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

All facility ownership & control disclosures 3

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

FacilityTypeRoleSince
Pendleton County High School-School Based Health CenterFranklin, WV, CCN 511055 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jul 15, 2014
Franklin Elementary School - School Based Health CenterFranklin, WV, CCN 511056 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jul 15, 2014
Brandywine Elementary School - School Based Health CenterBrandywine, WV, CCN 511057 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jul 15, 2014

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 3

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

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": "1405382400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1465862400000",
    "number": "1386051035",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 100",
            "city": "FRANKLIN",
            "state": "WV",
            "postal_code": "268070100",
            "telephone_number": "304-358-2355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 SCHOOL LANE",
            "city": "CIRCLEVILLE",
            "state": "WV",
            "postal_code": "268040187",
            "telephone_number": "304-567-3193"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENDLETON COMMUNITY CARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-07-15",
        "last_updated": "2016-06-14",
        "status": "A",
        "authorized_official_last_name": "HUDSON",
        "authorized_official_first_name": "JAIME",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "304-358-2355"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "North Fork Elementary School SBHC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Circleville, WV

Sources for this page

Verify at the official NPI Registry.