Arkadelphia Clinic for Children and Young Adults, PA

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

Legal business name

ARKADELPHIA CLINIC FOR CHILDREN AND YOUNG ADULTS, PA

Practice address

2850 Twin Rivers Dr
Arkadelphia, AR 71923-4212

Phone

(870) 246-8036

Fax

(870) 246-7164

NPI assigned

Oct 24, 2019

Last updated

Oct 24, 2019By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Gari M RuckerNPI 1972579316

Title

Delegated Official

Phone

(870) 246-8036

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in AR

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467095133. Details of each certification follow.

• CCN 043904 Rural health clinic · Active · Details

Rural health clinic certification: CCN 043904

Legal name

ARKADELPHIA CLINIC FOR CHILDREN AND YOUNG ADULTS, PA

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Nov 8, 2019

Last certification

Oct 25, 2022

Ownership / control type

1B

Organization structure

CorporationProprietary

Incorporated

Oct 28, 1998 in AR

Enrollment address

2850 Twin Rivers Dr
Arkadelphia, AR 71923-4212

Other NPIs on the same Medicare enrollment 1

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

• Arkadelphia Clinic for Children and Young Adults, PA

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1699741033

  O20190806000248

  Same enrollment

Locations

Interoperability endpoints

• FHIR API: https://fhir4.healow.com/fhir/r4/HJABAA

All disclosed owners & managing parties 4

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

Owners & managing parties with NPI records 3

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

• Carl Wesley Kluck, M.D.

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1508837485

  5% Or Greater Direct Ownership Interest, Corporate Director, Corporate Officer, W-2 Managing Employee

  CMS ownership
• David James Pennington, M.D.

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1023540275

  5% Or Greater Direct Ownership Interest, Corporate Director, Corporate Officer, W-2 Managing Employee

  CMS ownership
• Gari M Rucker, M.D.

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1972579316

  5% Or Greater Direct Ownership Interest, Corporate Director, Corporate Officer, W-2 Managing Employee

  CMS ownership

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.

• Gari M Rucker, M.D.

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1972579316
  NPD Authorized official
• Carl Wesley Kluck, M.D.

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1508837485
  NPD
• Joan E Kyle, M.D.

  • Pediatrics Physician
  • Arkadelphia, AR
  • NPI 1881660223
  NPD

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

{
    "created_epoch": "1571875200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1571875200000",
    "number": "1467095133",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2850 TWIN RIVERS DR",
            "city": "ARKADELPHIA",
            "state": "AR",
            "postal_code": "719234212",
            "telephone_number": "870-246-8036",
            "fax_number": "870-246-7164"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2850 TWIN RIVERS DR",
            "city": "ARKADELPHIA",
            "state": "AR",
            "postal_code": "719234212",
            "telephone_number": "870-246-8036",
            "fax_number": "870-246-7164"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ARKADELPHIA CLINIC FOR CHILDREN AND YOUNG ADULTS, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-10-24",
        "last_updated": "2019-10-24",
        "status": "A",
        "authorized_official_last_name": "RUCKER",
        "authorized_official_first_name": "GARI",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "DELEGATED OFFICIAL",
        "authorized_official_telephone_number": "870-246-8036"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ashley Celeste Angel, ST
• Angelic Care Home Health LLC
• Nakia Nijee Anthony
• Alex Jim Arce
• Christina Argo
• Arkadelphia Clinic for Children and Young Adults, PA
• Arkadelphia Eye Clinic Inc.
• Arkadelphia Health and Family Clinic, LLC
• Arkadelphia Medical Clinic
• Arkadelphia Physical Therapy Center, Inc.

• Rural Health Clinic/Center in Arkadelphia, AR
• Providers in Arkadelphia, AR by specialty
• Rural Health Clinic/Center in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2019; 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.

Verify at the official NPI Registry.