NPIMap

Organization Active NPI

South Central Missouri Community Health Center

  • Federally Qualified Health Center (FQHC)
  • St. Robert, MO
National Provider Identifier
1558070102
Registry record updated Nov 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
Practice address
165 Park Drive
St. Robert, MO 65584
Phone
(573) 426-2407
NPI assigned
Nov 22, 2022
Organization subpart
Yes
Parent organization
SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 22, 2022

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

Authorized official

Name
Elizabeth Sparks
Title
Credentialing Specialist
Phone
(573) 426-2407

Specialties & licenses 1

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

Addresses

Primary practice location

165 Park Drive
St. Robert, MO 65584

Mailing address

1081 E 18TH St
Rolla, MO 65401-2448
Phone (573) 426-2407

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20111013000097 MO Part B Supplier - Clinic/Group Practice 1355513581 Receives reassigned benefits from 27 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rolla, MO; Cuba, MO; Salem, MO; Saint Robert, MO
O20230228001666 MO Part A Provider - Federally Qualified Health Center (FQHC) 1355513581 Practice locations: Saint Robert, MO

Federally qualified health center certification: CCN 261926

Legal name
SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
Doing business as
FOUR RIVERS COMMUNITY HEALTH CENTER ST. ROBERT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 14, 2023
Last certification
Feb 14, 2023
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
in MO
Enrollment address
165 Park Dr
Saint Robert, MO 65584-7860

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 6

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

National Provider Directory

National Provider Directory
Tax ID family
South Central Missouri Community Health Center13 organizations share this tax ID, including this one
Part of
South Central Missouri Community Health Center

Other organizations with this tax ID 12

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

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Stuart Gipson Individual Corporate OfficerCeo Feb 17, 2020 100%
W-2 Managing EmployeeCeo Feb 17, 2021 100%

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Your Community Health CenterRolla, MO, CCN 261070 Federally qualified health center Operational/Managerial Control (100%) Sep 1, 2014
Four Rivers Community Health CenterRolla, MO, CCN 791034 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Sep 11, 2023

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1669075200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669075200000",
    "number": "1558070102",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1081 E 18TH ST",
            "city": "ROLLA",
            "state": "MO",
            "postal_code": "654012448",
            "telephone_number": "573-426-2407",
            "fax_number": "573-426-6723"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "165 PARK DRIVE",
            "city": "ST. ROBERT",
            "state": "MO",
            "postal_code": "65584",
            "telephone_number": "573-426-2407"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER",
        "enumeration_date": "2022-11-22",
        "last_updated": "2022-11-22",
        "certification_date": "2022-11-15",
        "status": "A",
        "authorized_official_last_name": "SPARKS",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "573-426-2407"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in St. Robert, MO

Sources for this page

Verify at the official NPI Registry.