South Central Missouri Community Health Center
Organization Active NPI Federally Qualified Health Center (FQHC) · Cuba, MO
NPI 1629875141 · NPPES record last updated Mar 3, 2025
Key facts
- NPI
- 1629875141
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
- Practice address
- 408 S Franklin St
Cuba, MO 65453-1408 - Phone
- (573) 426-4455
- Fax
- (573) 426-6723
- NPI assigned
- Mar 3, 2025
- Organization subpart
- No
Authorized official
- Name
- Stuart Gipson
- Title
- Ceo
- Phone
- (573) 426-4455
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 6
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 12
Practitioners 13
-
Dawn May Cavender-Erangey, APRN, FNP-BC
-
Hallie Caroline Davis, NURSE PRACTITIONER
-
Matthew Timothy Porter, M.D.
-
Yvonne M Prince, M.D.
-
Dawn Renee Tope, FNP
-
Alexis West, DNP
-
Margaret Ann Matlock, APRN-C
-
Mary K Zielke, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Federally qualified health center certification: CCN 791922
- Legal name
- SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
- Doing business as
- FOUR RIVERS COMMUNITY HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Oct 17, 2025
- Last certification
- Oct 17, 2025
- Ownership / control type
- For profit – corporation
- Organization structure
- Other · Non-profit
- Enrollment address
- 408 S Franklin St
Cuba, MO 65453-1408
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Lawrence West |
Corporate Director |
Sep 1, 2025 | 100% |
| Josephine Waltman |
Corporate Director |
Sep 1, 2025 | 100% |
| Virginia Pherigo |
Corporate Director |
Sep 1, 2025 | 100% |
| Don Payne |
Corporate Director |
Sep 1, 2025 | 100% |
| David Duncan |
Corporate Director |
Sep 1, 2025 | 100% |
| Chris Holliday |
Corporate Officer |
Sep 1, 2025 | 100% |
| Matt Koylu |
Corporate Director |
Sep 1, 2025 | 100% |
| Jane Victor |
Corporate Director |
Sep 1, 2025 | 100% |
| Deborah Frost |
Corporate Officer |
Sep 1, 2025 | 100% |
| Stuart Gipson |
Corporate Officer |
Sep 1, 2025 | 100% |
| W-2 Managing Employee | Mar 1, 2021 | 100% | |
| Angie Nappier |
Corporate Director |
Sep 1, 2025 | 100% |
| Stephanie Ann Martensen |
Corporate Director |
Sep 1, 2025 | 100% |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Your Community Health Center |
Federally qualified health center | Operational/Managerial Control (100%) | Sep 1, 2014 |
| Four Rivers Community Health Center |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Sep 11, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
| O20251006000845 | MO | Part a Provider - Federally Qualified Health Center (FQHC) | 1355513581 | Practice locations: Cuba, MO |
National Provider Directory
- Tax ID family
- South Central Missouri Community Health Center
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
408 S Franklin St
Cuba, MO 65453-1408
Mailing address
1081 E 18TH St
Rolla, MO 65401-2448
Phone (573) 426-4455
Other names
- Four Rivers Community Health Center
Other providers in Cuba, MO
- Patrycia Sellers
- Terry L. Sellers
- Aleksander Douglas Shelton
- Christian Shelton
- SJ Black Investments LLC
- St Johns Clinic Inc
- Stubblefield Enterprises Inc.
- Stubblefield Manor CNSL Operation LLC
- Amirah Binti Tan Abdullah
- Shelly B Tash
All providers in Cuba, MO · Federally Qualified Health Center (FQHC) in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 3, 2025. 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.