NPIMap

Organization Active NPI

Crusaders Central Clinic Association

  • Federally Qualified Health Center (FQHC)
  • Rockford, IL
National Provider Identifier
1508306861
Registry record updated Aug 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Practice address
1215 N Alpine Rd
Rockford, IL 61107-2201
Phone
(815) 490-1600
NPI assigned
Mar 6, 2017
Organization subpart
Yes
Parent organization
CRUSADERS CENTRAL CLINIC ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 24, 2022

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

Authorized official

Name
Samuel Miller
Title
President & Ceo
Phone
(815) 490-1737

Specialties & licenses 1

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

Addresses

Primary practice location

1215 N Alpine Rd
Rockford, IL 61107-2201

Mailing address

1215 N Alpine Rd
Rockford, IL 61107-2201
Phone (815) 490-1600

Other names 1

  • Crusader Community Health Alpine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031216000642 IL Part B Supplier - Clinic/Group Practice 5799682993 Receives reassigned benefits from 19 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Belvidere, IL; Loves Park, IL; Rockford, IL; South Beloit, IL
O20170620000014 IL Part A Provider - Federally Qualified Health Center (FQHC) 5799682993 Practice locations: Rockford, IL

Federally qualified health center certification: CCN 781874

Legal name
CRUSADERS CENTRAL CLINIC ASSOCIATION
Doing business as
CRUSADER COMMUNITY HEALTH ON ALPINE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 20, 2017
Last certification
Jun 20, 2017
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Mar 30, 2017 in IL
Enrollment address
1215 N Alpine Rd
Rockford, IL 61107-2201

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 8

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

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
14D2129794Crusader Community Health on Alpine1215 N Alpine Rd, Rockford, IL 61107Provider-performed microscopyMay 31, 2027

National Provider Directory

National Provider Directory
Tax ID family
Crusaders Central Clinic Association10 organizations share this tax ID, including this one
Part of
Crusaders Central Clinic Association

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 12

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

NameRoleSinceShare
Catherine L Brown Individual Corporate Director Jan 1, 2019
David Ruffin Individual Corporate Officer Jan 6, 2022
Peter J Mazanec Individual Corporate Officer Nov 10, 2019
James R Millikin Individual Corporate OfficerBoard Member Mar 30, 2017
Noel D Nickel Individual W-2 Managing Employee Dec 1, 2025
David W Powell Individual Corporate Officer Feb 10, 2020
Dennis Roop Individual Corporate Officer Jan 10, 2021
Leon E Hansen Individual Corporate OfficerBoard Member Mar 30, 2017
Barbara Williams Individual Corporate Officer Jan 10, 2016
Janice Forrest Individual Corporate Officer Sep 10, 2020
Richard P Walsh Individual Corporate OfficerBoard Member Mar 30, 2017
Samuel Miller Individual Corporate OfficerPresident & Ceo Mar 30, 2017
W-2 Managing EmployeePresident & Ceo Jan 1, 2020

NPI Registry JSON

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

{
    "created_epoch": "1488758400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661299200000",
    "number": "1508306861",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1215 N ALPINE RD",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611072201",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1215 N ALPINE RD",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611072201",
            "telephone_number": "815-490-1600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRUSADERS CENTRAL CLINIC ASSOCIATION",
        "enumeration_date": "2017-03-06",
        "last_updated": "2022-08-24",
        "certification_date": "2022-08-11",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "815-490-1737"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crusader Community Health Alpine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Crusader Community Health Alpine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rockford, IL

Sources for this page

Verify at the official NPI Registry.