NPIMap

Organization Active NPI

Boone Physician Services, LLC

Doing business as Centralia Family Health Clinic

  • Rural Health Clinic/Center
  • Centralia, MO
National Provider Identifier
1619648532
Registry record updated Sep 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BOONE PHYSICIAN SERVICES, LLC
Doing business as
Centralia Family Health Clinic
Practice address
1021 E Highway 22
Centralia, MO 65240-1183
Phone
(573) 682-5588
Fax
(573) 682-1539
NPI assigned
Sep 21, 2021
Last updated
Sep 21, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 21, 2021

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

Authorized official

Name
Brian Lee Winn
Title
Director of Finance
Phone
(573) 815-3269

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1021 E Highway 22
Centralia, MO 65240-1183

Mailing address

1021 E Highway 22
Centralia, MO 65240-1183
Phone (573) 682-5588

Other names 1

  • Centralia Family Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211004002355 MO Part A Provider - Rural Health Clinic 6507090644 Practice locations: Centralia, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1619648532. Details of each certification follow.

Rural health clinic certification: CCN 268983

Legal name
BOONE PHYSICIAN SERVICES LLC
Doing business as
CENTRALIA FAMILY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 4, 2008
Last certification
Jan 19, 2022
Ownership / control type
2B
Most recent change of ownership
Apr 1, 2021 (1 total)
Organization structure
LLCNon-profit
Incorporated
Jul 3, 2012 in MO
Enrollment address
1021 E Highway 22
Centralia, MO 65240-1183

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Boone Physician Services LLC5 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.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Brian L Winn Individual W-2 Managing EmployeeDirector of Finance Nov 17, 2023
Edward J Clayton Individual Corporate OfficerCfo Sep 1, 2022
W-2 Managing EmployeeCfo Sep 1, 2022
Operational/Managerial ControlCfo Sep 1, 2022
CH Allied Services, Inc. Organization, Columbia, MO Corporation, Non-profit 5% Or Greater Direct Ownership Interest Nov 4, 2008 100%

Owners & managing parties with NPI records 2

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

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Change-of-ownership history 1

DateEventCounterparty
Apr 1, 2021 Change of OwnershipThis provider was the buyer Centralia Family Health ClinicCCN 268983, MO, NPI 1164615316

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

NPI Registry JSON

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

{
    "created_epoch": "1632182400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632182400000",
    "number": "1619648532",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1021 E HIGHWAY 22",
            "city": "CENTRALIA",
            "state": "MO",
            "postal_code": "652401183",
            "telephone_number": "573-682-5588",
            "fax_number": "573-682-1539"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1021 E HIGHWAY 22",
            "city": "CENTRALIA",
            "state": "MO",
            "postal_code": "652401183",
            "telephone_number": "573-682-5588",
            "fax_number": "573-682-1539"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOONE PHYSICIAN SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-09-21",
        "last_updated": "2021-09-21",
        "certification_date": "2021-09-03",
        "status": "A",
        "authorized_official_last_name": "WINN",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "DIRECTOR OF FINANCE",
        "authorized_official_telephone_number": "573-815-3269"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Centralia Family Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Centralia, MO

Sources for this page

Verify at the official NPI Registry.