NPIMap

Organization Active NPI

Pikeville Clinic, LLC

  • Family Nurse Practitioner
  • Pikeville, TN
National Provider Identifier
1639472137
Registry record updated Nov 21, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
Legal business name
PIKEVILLE CLINIC, LLC
Practice address
3062 Main St
Pikeville, TN 37367-5746
Phone
(423) 447-2955
Fax
(423) 447-2405
NPI assigned
Dec 6, 2010
Last updated
Nov 21, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 21, 2013

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

Authorized official

Name
Ruth E. Boynton, APNNPI 1922083930
Title
Member
Phone
(423) 447-2955

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X NU Primary
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

3062 Main St
Pikeville, TN 37367-5746

Mailing address

PO Box 349
Pikeville, TN 37367-0349
Phone (423) 447-2955

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110131000344 TN Part B Supplier - Clinic/Group Practice 4880873371 Receives reassigned benefits from 3 practitioners
Practice locations: Pikeville, TN
O20130923000806 TN Part A Provider - Rural Health Clinic 4880873371 Practice locations: Pikeville, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639472137. Details of each certification follow.

Rural health clinic certification: CCN 448933

Legal name
PIKEVILLE CLINIC, LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 27, 2014
Last certification
Jul 22, 2019
Ownership / control type
1C
Organization structure
LLCProprietary
Enrollment address
3062 Main St
Pikeville, TN 37367-5746

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D0309708Pikeville Clinic3062 Main St, Pikeville, TN 37367Certificate of waiverDec 20, 2026

National Provider Directory

National Provider Directory

Locations

3062 Main St
Pikeville, TN 37367
Phone (423) 447-2955

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
Amie S Rainey Individual 5% Or Greater Direct Ownership InterestPartner Jun 10, 2011 50%
Ruth E Boynton Individual Operational/Managerial ControlPartner Nov 16, 2010 100%
Desiree Brock-Hudson Individual 5% Or Greater Direct Ownership Interest Jan 1, 2020

Owners & managing parties with NPI records 3

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

Practitioners & affiliated clinicians

Practitioners 4

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": "1291593600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1384992000000",
    "number": "1639472137",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 349",
            "city": "PIKEVILLE",
            "state": "TN",
            "postal_code": "373670349",
            "telephone_number": "423-447-2955",
            "fax_number": "423-447-2405"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3062 MAIN ST",
            "city": "PIKEVILLE",
            "state": "TN",
            "postal_code": "373675746",
            "telephone_number": "423-447-2955",
            "fax_number": "423-447-2405"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PIKEVILLE CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-12-06",
        "last_updated": "2013-11-21",
        "status": "A",
        "authorized_official_last_name": "BOYNTON",
        "authorized_official_first_name": "RUTH",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "423-447-2955",
        "authorized_official_credential": "APN"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pikeville, TN

Sources for this page

Verify at the official NPI Registry.