NPIMap

Organization Active NPI

Board of Governors of Dallas County Medical Center

Doing business as Nutt-Walley Clinic of Dallas County Medical Center

  • Rural Health Clinic/Center
  • Fordyce, AR
National Provider Identifier
1508364241
Registry record updated Jan 29, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Doing business as
Nutt-Walley Clinic 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
Last updated
Jan 29, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 29, 2018

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

Authorized official

Name
Kenneth E Sanders
Title
Administrator
Phone
(870) 352-6363

Specialties & licenses 2

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

Addresses

Primary practice location

110 N Clifton St
Fordyce, AR 71742-3025

Mailing address

110 N Clifton St
Fordyce, AR 71742-3025

Other names 1

  • Nutt-Walley Clinic of Dallas County Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508364241. Details of each certification follow.

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
OtherNon-profit
Incorporated
Sep 13, 2002 in AR
Enrollment address
110 N Clifton St
Fordyce, AR 71742-3065
Related CCNs
041317

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory
Tax ID family
Board of Governors Dallas5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Locations

110 N Clifton St
Fordyce, AR 71742
Phone (870) 352-3525

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Kevin Kauffman Individual Corporate Officer Mar 1, 2018
John Daniel Individual Corporate Officer Mar 1, 2018
B D Hargett Individual Corporate Officer Mar 1, 2018
Thomas Denton Individual Corporate OfficerCeo May 1, 2026
Corporate DirectorCeo May 1, 2026
W-2 Managing EmployeeCeo May 1, 2026
Don Harris Individual Corporate Officer Mar 1, 2018
Board of Governors of Dallas County Medical Center Organization, Fordyce, AR 5% Or Greater Direct Ownership Interest Mar 1, 2018 100%
Duane Brewer Individual Corporate Officer Mar 1, 2018

Owners & managing parties with NPI records 4

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

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 10

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": "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

Sources for this page

Verify at the official NPI Registry.