Clinch Professional Physician Services LLC
Organization Active NPI Rural Health Clinic/Center · Cedar Bluff, VA
NPI 1669157285 · NPPES record last updated Sep 24, 2024
Key facts
- NPI
- 1669157285
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- CLINCH PROFESSIONAL PHYSICIAN SERVICES LLC
- Practice address
- 1100 Cedar Valley Dr Ste 3
Cedar Bluff, VA 24609-9247 - Phone
- (276) 596-6449
- NPI assigned
- Jun 20, 2023
- Organization subpart
- No
Authorized official
- Name
- Charlotte Lawrence
- Title
- Secretary
- Phone
- (615) 920-7000
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 1
Facilities with the same owner 193
Practitioners 90
-
Sami S Abdul Jawad, M.D.
-
Darren S Baroni, MD
-
Robert Allen Bishop, FNP-BC
-
Holly Blankenship, FNP-BC
-
Kevin Patrick Carter, AU.D.
-
Tracy M Downs, M.D.
-
Keshia Brooke Hackworth, FNP-BC
-
Susan Renee Harris, FNP-C
-
Tammy Hurley, FNP
-
Zaven Jabourian, MD
-
Hao Duy Pham, M.D.
-
Vijay Ramakrishnan, M.D.
-
Dara Ratliff, FNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 49D2104039 | Clinch Professional Physicians Services, LLC | Certificate of waiver | Oct 25, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in VA
Rural health clinic certification: CCN 498943
- Legal name
- CLINCH PROFESSIONAL PHYSICIAN SERVICES LLC
- Doing business as
- CLINCH VALLEY FAMILY CARE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Nov 28, 2023
- Last certification
- Nov 28, 2023
- Ownership / control type
- 1B
- Organization structure
- LLC · Proprietary
- Incorporated
- Feb 20, 2007 in VA
- Enrollment address
- 1100 Cedar Valley Dr
Ste 3
Cedar Bluff, VA 24609-9247
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Pamela Kane |
Corporate Officer |
Jul 1, 2023 | |
| DSB Acquisition LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 100% |
| Laura C Hinson |
Corporate Officer |
Mar 12, 2025 | |
| Lifepoint Health Inc |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 100% |
| Charlotte E Lawrence |
Corporate Officer |
Jul 1, 2023 | |
| Elliott Brown |
Corporate Officer |
Apr 2, 2026 | |
| Lifepoint Acquisition Corp |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 100% |
| Klaus Michael Boel |
Corporate Officer |
Aug 19, 2024 | |
| W-2 Managing Employee | Aug 19, 2024 | ||
| Christopher J Monte |
Corporate Officer |
Jul 1, 2023 | |
| Lifepoint VA Holdings Inc |
5% Or Greater Direct Ownership Interest | Jul 1, 2023 | 100% |
| Legacy Lifepoint Health LLC |
5% Or Greater Indirect Ownership Interest | Jul 1, 2023 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070709000505 | VA | Part B Supplier - Clinic/Group Practice | 9436259223 |
Receives reassigned benefits from 82 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Richlands, VA; Cedar Bluff, VA; Bluefield, VA; Pounding Mill, VA |
| O20230721002206 | VA | Part a Provider - Rural Health Clinic | 9436259223 | Practice locations: Cedar Bluff, VA |
National Provider Directory
- Tax ID family
- Clinch Professional Physician Services
Locations
1934 Leatherwood Ln
Bluefield, VA 24605
Phone (276) 596-6563
1100 Cedar Valley Dr
Ste 3
Cedar Bluff, VA 24609
Phone (276) 596-6449
398 Clinic Rd
Cedar Bluff, VA 24609
Phone (276) 963-6600
1114 E Main St
Lebanon, VA 24266
Phone (276) 596-6786
13395 Governor G C Peery Hwy
Pounding Mill, VA 24637
Phone (276) 596-6375
6719 Governor Gc Peery Hwy
Ste 1600
Richlands, VA 24641
Phone (276) 596-6725
6719 Governor Gc Peery Hwy
Ste 1800
Richlands, VA 24641
Phone (276) 596-6659
6719 Governor Gc Peery Hwy
Ste 1200
Richlands, VA 24641
Phone (276) 963-2535
6719 Governor Gc Peery Hwy
Ste 2450
Richlands, VA 24641
Phone (276) 596-6786
6719 Governor Gc Peery Hwy
Ste 1250
Richlands, VA 24641
Phone (276) 596-6695
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
1100 Cedar Valley Dr Ste 3
Cedar Bluff, VA 24609-9247
Mailing address
330 Seven Springs Way
Brentwood, TN 37027-5098
Phone (615) 920-7000
Other names
- Clinch Valley Family Care
Other providers in Cedar Bluff, VA
- Crystal Chafin
- Bell A Charles
- Claypool Hill Physical Therapy
- Heath Clevinger
- Tiffany Clevinger
- Clinch Valley Physicians Associates LLC
- Clinch Valley Treatment Center
- Clinch Valley Treatment Center
- Jordyn K Cole
- Kathy Lee Cole
All providers in Cedar Bluff, VA · Rural Health Clinic/Center in Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 24, 2024. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.