NPIMap

Organization Active NPI

Pines Health Services

Doing business as Pines Kimball Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Fort Fairfield, ME
National Provider Identifier
1508291089
Registry record updated Sep 4, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PINES HEALTH SERVICES
Doing business as
Pines Kimball Community Health Center
Practice address
11 Harmony LN
Fort Fairfield, ME 04742-3354
Phone
(207) 472-0590
Fax
(207) 472-0592
NPI assigned
Sep 4, 2013
Last updated
Sep 4, 2013By the provider in NPPES
Organization subpart
Yes
Parent organization
PINES HEALTH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 4, 2013

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

Authorized official

Name
Mr. James Davis
Title
Ceo
Phone
(207) 498-2359

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Clinical Social Worker 1041C0700X
Family Medicine Physician 207Q00000X

Addresses

Primary practice location

11 Harmony LN
Fort Fairfield, ME 04742-3354

Mailing address

PO Box 40
Caribou, ME 04736-0040
Phone (207) 498-1320

Other names 1

  • Pines Kimball Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040823001052 ME Part B Supplier - Clinic/Group Practice 0749275113 Receives reassigned benefits from 100 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Caribou, ME; Presque Isle, ME; Van Buren, ME
O20140109000923 ME Part A Provider - Federally Qualified Health Center (FQHC) 0749275113 Practice locations: Fort Fairfield, ME

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508291089. Details of each certification follow.

Federally qualified health center certification: CCN 201908

Legal name
PINES HEALTH SERVICES
Doing business as
PINES KIMBALL COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 13, 2014
Last certification
Jan 13, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 7, 1981 in ME
Enrollment address
11 Harmony LN
Fort Fairfield, ME 47423354

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory
Tax ID family
Pines Health Dba HLTH Q7 organizations share this tax ID, including this one
Part of
Pines Health Dba HLTH Q

Other organizations with this tax ID 6

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

Locations

11 Harmony Ln
Fort Fairfield, ME 04742
Phone (207) 472-0590

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Kristie Moir Individual Corporate DirectorBoard Member Feb 1, 2016
Betty Hatch Individual Corporate DirectorBoard Member Oct 1, 2010
Chelsea Desrosiers Individual Corporate DirectorBoard Member Jan 1, 2019
Diane Gove Individual Corporate DirectorBoard Member Feb 1, 2019
Jon Holabird Individual Corporate DirectorBoard Member Jan 1, 2023
Dana Rattray Individual Corporate DirectorBoard Member Feb 1, 2008
Tanya Sleeper Individual Corporate DirectorBoard Member Mar 1, 2009
Lisa Caron Individual Corporate OfficerCoo Nov 1, 2006
Stev B Rogeski Individual Corporate DirectorBoard Member Jan 1, 2013
Kris Doody Individual Corporate OfficerChief Executive Officer Jan 1, 2018
W-2 Managing EmployeeChief Executive Officer Jan 1, 2018

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 2

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": "1378252800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1378252800000",
    "number": "1508291089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 40",
            "city": "CARIBOU",
            "state": "ME",
            "postal_code": "047360040",
            "telephone_number": "207-498-1320",
            "fax_number": "207-498-1149"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 HARMONY LN",
            "city": "FORT FAIRFIELD",
            "state": "ME",
            "postal_code": "047423354",
            "telephone_number": "207-472-0590",
            "fax_number": "207-472-0592"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINES HEALTH SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PINES HEALTH SERVICES",
        "enumeration_date": "2013-09-04",
        "last_updated": "2013-09-04",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "207-498-2359",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pines Kimball Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Fairfield, ME

Sources for this page

Verify at the official NPI Registry.