Board of Governors of Dallas County Medical Center
Organization Active NPI Rural Health Clinic/Center · Fordyce, AR
NPI 1508364241 · NPPES record last updated Jan 29, 2018
Key facts
- NPI
- 1508364241
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
- Practice address
- 110 N Clifton St
Fordyce, AR 71742-3025 - Phone
- (870) 352-3525
- Fax
- (870) 352-3533
- NPI assigned
- Jan 29, 2018
- Organization subpart
- No
Authorized official
- Name
- Kenneth E Sanders
- Title
- Administrator
- Phone
- (870) 352-6363
Owners & managing parties with NPI records 4
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 4
Related certifications (CCN) 1
Practitioners 11
-
Jenna Bryant, APRN
-
David J Foscue, M.D. , PA
-
Christal Martindale, ANP
-
Cory Andrew McMahon, APRN
-
Lindsey N Walley, M.D.
-
Madeline Reed, DNP, APRN, PMHNP-BC
-
Khaled Hassan, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in AR
Rural health clinic certification: CCN 048515
- Legal name
- BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
- Doing business as
- NUTT-WALLEY CLINIC OF DALLAS COUNTY MEDICAL CENTER
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 1, 2018
- Last certification
- Jul 27, 2018
- Ownership / control type
- 2B
- Organization structure
- Other · Non-profit
- Incorporated
- Sep 13, 2002 in AR
- Enrollment address
- 110 N Clifton St
Fordyce, AR 71742-3065 - Related CCNs
- 041317
All disclosed owners & managing parties 7
| Name | Role | Since | Share |
|---|---|---|---|
| Kevin Kauffman |
Corporate Officer | Mar 1, 2018 | |
| John Daniel |
Corporate Officer | Mar 1, 2018 | |
| B D Hargett |
Corporate Officer | Mar 1, 2018 | |
| Thomas Denton |
Corporate Officer |
May 1, 2026 | |
| Corporate Director |
May 1, 2026 | ||
| W-2 Managing Employee |
May 1, 2026 | ||
| Don Harris |
Corporate Officer | Mar 1, 2018 | |
| Board of Governors of Dallas County Medical Center |
5% Or Greater Direct Ownership Interest | Mar 1, 2018 | 100% |
| Duane Brewer |
Corporate Officer | Mar 1, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040302000815 | AR | Part B Supplier - Clinic/Group Practice | 7416869300 |
Receives reassigned benefits from 14 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Fordyce, AR |
| O20180221000855 | AR | Part a Provider - Rural Health Clinic | 7416869300 |
1 other NPI on this enrollment Practice locations: Fordyce, AR |
National Provider Directory
- Tax ID family
- Dallas County Medical C
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
110 N Clifton St
Fordyce, AR 71742-3025
Mailing address
110 N Clifton St
Fordyce, AR 71742-3025
Other names
- Nutt-Walley Clinic of Dallas County Medical Center
NPI Registry JSON
{
"created_epoch": "1517184000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1517184000000",
"number": "1508364241",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "110 N CLIFTON ST",
"city": "FORDYCE",
"state": "AR",
"postal_code": "717423025"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "110 N CLIFTON ST",
"city": "FORDYCE",
"state": "AR",
"postal_code": "717423025",
"telephone_number": "870-352-3525",
"fax_number": "870-352-3533"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER",
"organizational_subpart": "NO",
"enumeration_date": "2018-01-29",
"last_updated": "2018-01-29",
"status": "A",
"authorized_official_last_name": "SANDERS",
"authorized_official_first_name": "KENNETH",
"authorized_official_middle_name": "E",
"authorized_official_title_or_position": "ADMINISTRATOR",
"authorized_official_telephone_number": "870-352-6363"
},
"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": [
{
"organization_name": "Nutt-Walley Clinic of Dallas County Medical Center",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Fordyce, AR
- Matthew Thomas Bird
- Board of Governors of Dallas County Medical Center
- Board of Governors of Dallas County Medical Center
- Board of Governors of Dallas County Medical Center
- Board of Governors of Dallas County Medical Center
- Board of Governors of Dallas County Medical Center
- Board of Governors of Dallas County Medical Center
- Cherie Ann Bonanno
- Kristen F Boren
- Leslie Brandon
All providers in Fordyce, AR · Rural Health Clinic/Center in Arkansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 29, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.