NPIMap

Organization Active NPI

Tri County Community Health Council Inc.

Doing business as CommWell Health

  • Federally Qualified Health Center (FQHC)
  • Dunn, NC
National Provider Identifier
1649414517
Registry record updated Mar 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC.
Doing business as
CommWell Health
Practice address
1508 Maple Grove Church Rd Ste B
Dunn, NC 28334-7688
Phone
(877) 935-5255
Fax
(910) 236-2118
NPI assigned
Apr 23, 2009
Last updated
Mar 27, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 27, 2024

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

Authorized official

Name
William C Ellison
Title
Revenue Cycle Manager
Phone
(910) 567-7065

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Adult Mental Health Clinic/Center 261QM0850X MHL082078 NC

Addresses

Primary practice location

1508 Maple Grove Church Rd Ste B
Dunn, NC 28334-7688

Mailing address

PO Box 340
Four Oaks, NC 27524-0340
Phone (910) 567-6194

Other identifiers 4

IdentifierTypeStateIssuer
5917548MedicaidNC
6008040MedicaidNC
34-1973OtherNCMEDICARE OSCAR
8302723MedicaidNC

Other names 1

  • CommWell Health Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040702000780 NC Part B Supplier - Clinic/Group Practice 2163409558 Receives reassigned benefits from 52 practitioners
19 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Willard, NC; Tar Heel, NC; Smithfield, NC; Shallotte, NC; Dunn, NC; Salemburg, NC; Ocean Isle Beach, NC; Harrells, NC…
O20120615000228 NC Part A Provider - Federally Qualified Health Center (FQHC) 2163409558 Practice locations: Dunn, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649414517. Details of each certification follow.

Federally qualified health center certification: CCN 341973

Legal name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC
Doing business as
COMMWELL HEALTH OF NEWTON GROVE/SPIVEY'S CORNER- BEHAVIORAL HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 15, 2012
Last certification
Jun 15, 2012
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 21, 1977 in NC
Enrollment address
1508 Maple Grove Church Rd
Ste B
Dunn, NC 28334-7688

Other NPIs with the same Medicare PAC ID 15

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

View all 15

Other NPIs on the same Medicare enrollment 19

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

View all 19

National Provider Directory

National Provider Directory
Tax ID family
Tri County Community Health25 organizations share this tax ID, including this one

Other organizations with this tax ID 24

Organizations that report the same tax identification number in the National Provider Directory.

View all 24

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
Nancy J Blackman Individual Corporate DirectorBoard of Directors Feb 1, 2011
Phillip E Mills Individual Corporate DirectorBoard of Directors Feb 1, 2011
Vanessa a Burgess Individual Corporate DirectorBoard of Directors Feb 1, 2011
Raymond Lindsey Individual Corporate DirectorBoard of Directors Feb 1, 2011
Kenneth a Cabral Individual Corporate DirectorBoard of Directors Apr 18, 2015
Nathan J Tilghman Individual Corporate DirectorBoard of Directors Feb 1, 2011
Mary Crumpler Individual Corporate DirectorBoard of Director Mar 17, 2015
Silvia a. Cendejas Individual Corporate DirectorBoard of Directors Dec 15, 2011
Gary Herring Individual Corporate DirectorBoard of Director Mar 16, 2016
Spencer McAlpine Individual Corporate DirectorBoard of Director Aug 29, 2013
William Taylor Individual Corporate DirectorBoard of Director May 18, 2017
Jose Garcia Individual Corporate DirectorBoard of Directors Aug 1, 2019
Pamela Tripp Individual W-2 Managing EmployeePresident/Ceo Feb 1, 2011 100%
Mary E Blaizes Individual Corporate DirectorBoard of Directors Feb 1, 2011
William C Ellison Individual Corporate DirectorBoard of Directors Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 7

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": "1240444800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711497600000",
    "number": "1649414517",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 340",
            "city": "FOUR OAKS",
            "state": "NC",
            "postal_code": "275240340",
            "telephone_number": "910-567-6194",
            "fax_number": "910-567-5552"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1508 MAPLE GROVE CHURCH RD STE B",
            "city": "DUNN",
            "state": "NC",
            "postal_code": "283347688",
            "telephone_number": "877-935-5255",
            "fax_number": "910-236-2118"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI COUNTY COMMUNITY HEALTH COUNCIL INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-04-23",
        "last_updated": "2024-03-27",
        "certification_date": "2024-03-27",
        "status": "A",
        "authorized_official_last_name": "ELLISON",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "REVENUE CYCLE MANAGER",
        "authorized_official_telephone_number": "910-567-7065"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "NC",
            "license": "MHL082078",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5917548",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6008040",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE OSCAR",
            "identifier": "34-1973",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8302723",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CommWell Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dunn, NC

Sources for this page

Verify at the official NPI Registry.