NPIMap

Boone Physician Services, LLC

Organization Active NPI Rural Health Clinic/Center · Centralia, MO

NPI 1619648532 · NPPES record last updated Sep 21, 2021

Key facts

NPI
1619648532
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
BOONE PHYSICIAN SERVICES, LLC
Practice address
1021 E Highway 22
Centralia, MO 65240-1183
Phone
(573) 682-5588
Fax
(573) 682-1539
NPI assigned
Sep 21, 2021
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 2

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

Other NPIs with the same Medicare PAC ID 4

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

Corporate family (same 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.

Change of ownership 1

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

Facilities with the same owner 3

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

Practitioners 243

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

View all 243

Medicare participation

Medicare fee-for-service enrollment
Enrolled in MO

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
LLC · Non-profit
Incorporated
Jul 3, 2012 in MO
Enrollment address
1021 E Highway 22
Centralia, MO 65240-1183

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 Employee
Director of Finance		 Nov 17, 2023
Edward J Clayton
Individual 		Corporate Officer
Cfo		 Sep 1, 2022
W-2 Managing Employee
Cfo		 Sep 1, 2022
Operational/Managerial Control
Cfo		 Sep 1, 2022
CH Allied Services, Inc.
Organization · Columbia, MO
Corporation, Non-profit 		5% Or Greater Direct Ownership Interest Nov 4, 2008 100%

Change-of-ownership history

DateEventCounterparty
Apr 1, 2021 Change of Ownership
This provider was the buyer		 Centralia Family Health Clinic
CCN 268983 · MO · NPI 1164615316

Medicare enrollment records

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

National Provider Directory

Tax ID family
Boone Physician Services LLC (5 organizations share this tax ID)

Specialties & licenses

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

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

  • Centralia Family Health Clinic Doing business as

Other providers in Centralia, MO

All providers in Centralia, MO · Rural Health Clinic/Center in Missouri

Sources for this page

Verify at the official NPI Registry.