NPIMap

Organization Active NPI

Centerville Clinics Inc

  • School Social Worker
  • Bobtown, PA
National Provider Identifier
1477039410
Registry record updated Jul 12, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
School Social WorkerTaxonomy code 1041S0200X
Legal business name
CENTERVILLE CLINICS INC
Practice address
Bobtown Elementary
304 Grant Street
Bobtown, PA 15315
Phone
(724) 839-7241
NPI assigned
Jul 12, 2018
Last updated
Jul 12, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 12, 2018

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

Authorized official

Name
Mr. Barry Niccolai
Title
Executive Director
Phone
(724) 632-6801

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
School Social Worker 1041S0200X PA Primary

Addresses

Primary practice location

Bobtown Elementary
304 Grant Street
Bobtown, PA 15315

Mailing address

Centerville Clinics Inc
1070 Old National Pike Road
Fredericktown, PA 15333-2114
Phone (724) 632-6801

Other identifiers 1

IdentifierTypeStateIssuer
10072884400MedicaidPA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210503002267 PA Part A Provider - Federally Qualified Health Center (FQHC) 7214837202 Practice locations: Bobtown, PA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477039410. Details of each certification follow.

Federally qualified health center certification: CCN 731802

Legal name
CENTERVILLE CLINICS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 28, 2021
Last certification
Apr 28, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 2, 1953 in PA
Enrollment address
304 Grant Street
Bobtown, PA 15315-1014

Other NPIs with the same Medicare PAC ID 23

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

View all 23

National Provider Directory

National Provider Directory

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.

NameRoleSinceShare
Daniel L Holt Individual W-2 Managing EmployeeMedical Director Jan 1, 2011
Donna Salvino Individual Corporate DirectorSecretary Treasurer Aug 25, 2014
Edward J Marotta Individual Corporate DirectorBoard Member Nov 17, 2014
Barry R Niccolai Individual Corporate OfficerExecutive Director Apr 1, 2017
W-2 Managing EmployeeManaging Employee Apr 1, 2017
Patricia a Gavazzi Individual Corporate DirectorBoard Member Jun 27, 2017
Darra Tyler-Owens Individual Corporate DirectorBoard Member Sep 29, 2018
Andrew Corfont Individual Corporate DirectorBoard Member Mar 25, 2013
Joseph M Yablonski Individual Corporate DirectorPresident of Board Nov 23, 2004
Patricia Martos Individual W-2 Managing EmployeeDirector of Finance & Personnel Mar 1, 1979
James T Yablonski Individual Corporate DirectorVice President Jan 23, 1995
Marianne E Gideon Individual Corporate DirectorBoard Member Jun 27, 2016

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1531353600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1531353600000",
    "number": "1477039410",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "CENTERVILLE CLINICS INC",
            "address_2": "1070 OLD NATIONAL PIKE ROAD",
            "city": "FREDERICKTOWN",
            "state": "PA",
            "postal_code": "153332114",
            "telephone_number": "724-632-6801",
            "fax_number": "724-632-6312"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "BOBTOWN ELEMENTARY",
            "address_2": "304 GRANT STREET",
            "city": "BOBTOWN",
            "state": "PA",
            "postal_code": "15315",
            "telephone_number": "724-839-7241"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTERVILLE CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-12",
        "last_updated": "2018-07-12",
        "status": "A",
        "authorized_official_last_name": "NICCOLAI",
        "authorized_official_first_name": "BARRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "724-632-6801",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "1041S0200X",
            "taxonomy_group": "",
            "desc": "Social Worker, School",
            "state": "PA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10072884400",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bobtown, PA

Sources for this page

Verify at the official NPI Registry.