NPIMap

Organization Active NPI

Park Duvalle Community Health Center, Inc

Doing business as Park Duvalle at Central Health Center

  • Federally Qualified Health Center (FQHC)
  • Louisville, KY
National Provider Identifier
1639727951
Registry record updated Nov 2, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Doing business as
Park Duvalle at Central Health Center
Practice address
1130 W Chestnut St
Louisville, KY 40203-2047
Phone
(502) 772-4401
NPI assigned
Aug 29, 2019
Last updated
Nov 2, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
PARK DUVALLE COMMUNITY HEALTH CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 2, 2021

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

Authorized official

Name
Swannie Jett
Title
Ceo
Phone
(502) 774-4401

Specialties & licenses 1

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

Addresses

Primary practice location

1130 W Chestnut St
Louisville, KY 40203-2047

Mailing address

3015 Wilson Ave
Louisville, KY 40211-1969
Phone (502) 774-4401

Other practice location 1

3015 Wilson Ave
Louisville, KY 40211-1969
Phone (502) 774-4401

Other identifiers 1

IdentifierTypeStateIssuer
31000011MedicaidKY

Other names 1

  • Park Duvalle at Central Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040302000539 KY Part B Supplier - Clinic/Group Practice 1658268974 Receives reassigned benefits from 32 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Eminence, KY; Louisville, KY; Taylorsville, KY
O20250124002202 KY Part A Provider - Federally Qualified Health Center (FQHC) 1658268974 Practice locations: Louisville, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639727951. Details of each certification follow.

Federally qualified health center certification: CCN B01156

Legal name
PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 23, 2025
Last certification
Jan 23, 2025
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
1130 W Chestnut St
Louisville, KY 40203-2047

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory
Part of
Park Duvalle Community Health Center Inc

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Darrell L Shaw Individual Corporate DirectorBoard Member Dec 9, 2024
Karan Samir Shah Individual Corporate DirectorBoard Member Dec 9, 2024
William Holden Individual Corporate DirectorBoard Member Dec 9, 2024
Alfred Smith Individual Corporate DirectorBoard Member Dec 9, 2024
Stacy Sowell Individual Corporate DirectorBoard Member Dec 9, 2024
Vickie Williams Individual Corporate DirectorBoard Member Dec 9, 2024
Shorye Payne Individual Corporate DirectorBoard Member Dec 9, 2024
Desmond L Robinson Individual Corporate DirectorTreasurer Dec 9, 2024
Katie Calloway Individual Corporate DirectorBoard Member Dec 9, 2024
Swannie Jett Individual 5% Or Greater Indirect Ownership InterestCeo Nov 1, 2021
W-2 Managing EmployeeAd; Dec 9, 2024
Operational/Managerial ControlCeo Dec 9, 2024
Barbara Mitchell Individual Corporate DirectorBoard Member Dec 9, 2024
Kevin Bruce Individual Corporate DirectorVice Chairperson Dec 9, 2024
Angela Wilson Individual Corporate DirectorBoard Member Dec 9, 2024
Deborah E Thomas Individual Corporate DirectorBoard Member Dec 9, 2024
Dwayne Compton Individual Corporate DirectorBoard Member Dec 9, 2024

Owners & managing parties with NPI records 1

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": "1567036800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635811200000",
    "number": "1639727951",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3015 WILSON AVE",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402111969",
            "telephone_number": "502-774-4401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1130 W CHESTNUT ST",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402032047",
            "telephone_number": "502-772-4401"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3015 Wilson Ave",
            "address_purpose": "LOCATION",
            "city": "Louisville",
            "state": "KY",
            "postal_code": "402111969",
            "country_code": "US",
            "telephone_number": "502-774-4401",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PARK DUVALLE COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PARK DUVALLE COMMUNITY HEALTH CENTER, INC",
        "enumeration_date": "2019-08-29",
        "last_updated": "2021-11-02",
        "certification_date": "2021-11-02",
        "status": "A",
        "authorized_official_last_name": "JETT",
        "authorized_official_first_name": "SWANNIE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "502-774-4401"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31000011",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Park Duvalle at Central Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Park Duvalle at Central Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Louisville, KY

Sources for this page

Verify at the official NPI Registry.