NPIMap

Organization Active NPI

Monterey Medical LLC

  • Rural Health Clinic/Center
  • Monterey, TN
National Provider Identifier
1497339790
Registry record updated Jul 8, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MONTEREY MEDICAL LLC
Practice address
400 W Crawford Ave
Monterey, TN 38574-1166
Phone
(931) 839-2224
Fax
(931) 839-2530
NPI assigned
May 12, 2021
Last updated
Jul 8, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 8, 2021

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

Authorized official

Name
Crystal Denise Vaughn
Title
Vice President
Phone
(931) 260-5756

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

400 W Crawford Ave
Monterey, TN 38574-1166

Mailing address

400 W Crawford Ave
Monterey, TN 38574-1166

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20210525002719 TN Part A Provider - Rural Health Clinic 7012316961 Practice locations: Crossville, TN; Monterey, TN
O20210811003455 TN Part B Supplier - Clinic/Group Practice 7012316961 Receives reassigned benefits from 15 practitioners
Practice locations: Crossville, TN; Monterey, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1497339790. Details of each certification follow.

Rural health clinic certification: CCN 883857

Legal name
MONTEREY MEDICAL LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 21, 2021
Last certification
Dec 21, 2021
Ownership / control type
1C
Organization structure
LLCProprietary
Enrollment address
400 W Crawford Ave
Monterey, TN 38574-1166

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D2224797Monterey Medical, LLC400 West Crawford Ave, Monterey, TN 38574Certificate of waiverMay 15, 2027

National Provider Directory

National Provider Directory

Locations

400 W Crawford Ave
Monterey, TN 38574
Phone (931) 839-2224

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Johnny Wayne Presley Individual 5% Or Greater Indirect Ownership Interest Dec 12, 2022 100%
Corporate OfficerPresident Dec 12, 2022 100%
W-2 Managing EmployeePresident Dec 12, 2022 100%
Operational/Managerial ControlPresident Dec 12, 2022 100%
Presley Health LLC Organization, Crossville, TN LLC 5% Or Greater Direct Ownership Interest Dec 12, 2022 100%

Owners & managing parties with NPI records 1

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

  • Johnny Wayne Presley, PAC
    • Medical Physician Assistant
    • Jamestown, TN
    • NPI 1427069749

    5% Or Greater Indirect Ownership Interest, Corporate Officer, Operational/Managerial Control, W-2 Managing Employee

    CMS ownership

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 15

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.

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1620777600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1625702400000",
    "number": "1497339790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 W CRAWFORD AVE",
            "city": "MONTEREY",
            "state": "TN",
            "postal_code": "385741166"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 W CRAWFORD AVE",
            "city": "MONTEREY",
            "state": "TN",
            "postal_code": "385741166",
            "telephone_number": "931-839-2224",
            "fax_number": "931-839-2530"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MONTEREY MEDICAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-12",
        "last_updated": "2021-07-08",
        "certification_date": "2021-07-08",
        "status": "A",
        "authorized_official_last_name": "VAUGHN",
        "authorized_official_first_name": "CRYSTAL",
        "authorized_official_middle_name": "DENISE",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "931-260-5756"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Monterey, TN

Sources for this page

Verify at the official NPI Registry.