NPIMap

Organization Active NPI

Lee County Cooperative Clinic

  • Federally Qualified Health Center (FQHC)
  • Marianna, AR
National Provider Identifier
1669480836
Registry record updated Sep 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LEE COUNTY COOPERATIVE CLINIC
Practice address
530 West Atkins Blvd
Marianna, AR 72360-2113
Phone
(870) 295-5225
Fax
(870) 295-6900
NPI assigned
Aug 4, 2006
Last updated
Sep 21, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 21, 2021

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

Authorized official

Name
Miss Ossie M Hall
Title
Cashier/Billing Supervisor
Phone
(870) 295-5225

Specialties & licenses 1

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

Addresses

Primary practice location

530 West Atkins Blvd
Marianna, AR 72360-2113

Mailing address

PO Box 669
Marianna, AR 72360-0669
Phone (870) 295-5225

Other identifiers 2

IdentifierTypeStateIssuer
117597749MedicaidAR
5G122OtherARMEDICARE GROUP PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20081213000190 AR Part B Supplier - Clinic/Group Practice 8921917204 Receives reassigned benefits from 9 practitioners
3 other NPIs on this enrollment
Practice locations: Marianna, AR; Wabash, AR; Madison, AR; Hughes, AR
O20100624000898 AR Part A Provider - Federally Qualified Health Center (FQHC) 8921917204 Practice locations: Marianna, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669480836. Details of each certification follow.

Federally qualified health center certification: CCN 041802

Legal name
LEE COUNTY COOPERATIVE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 1, 1991
Last certification
Dec 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 12, 1970 in AR
Enrollment address
558 Atkins Blvd
Marianna, AR 72360-2113
Related CCNs
041802

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory
Tax ID family
Lakeview Satellite Clinic4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Thomas Williams Individual Corporate DirectorBoard Member Jan 1, 2021
Cameshia Rogers Individual Corporate DirectorFinance Director Jun 3, 2019
W-2 Managing EmployeeFinance Director Mar 20, 2020
Lois Johnson Individual Corporate DirectorBoard Member Jan 1, 2021
Kim Brown Individual W-2 Managing EmployeeChief Compliance Officer/Cred. Coor Mar 20, 2020
Charlet Jones Individual Corporate OfficerBoard Member Jan 1, 2019
Carrie Carroll Individual Corporate DirectorBoard Member Jan 1, 2021
Desi Sims Individual Corporate OfficerBoard Member Jan 1, 2019
Quincy Scott Individual Corporate DirectorBoard Member Jan 1, 2021
Angela Moore Individual Corporate DirectorBoard Member Jan 1, 2021
Kellee Farris Individual Corporate DirectorCeo Sep 28, 2018
Virgie Lee Phillips Individual Corporate DirectorBoard Member Jan 1, 2021

Practitioners & affiliated clinicians

Practitioners 9

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": "1154649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632182400000",
    "number": "1669480836",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 669",
            "city": "MARIANNA",
            "state": "AR",
            "postal_code": "723600669",
            "telephone_number": "870-295-5225",
            "fax_number": "870-295-6900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "530 WEST ATKINS BLVD",
            "city": "MARIANNA",
            "state": "AR",
            "postal_code": "723602113",
            "telephone_number": "870-295-5225",
            "fax_number": "870-295-6900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEE COUNTY COOPERATIVE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-04",
        "last_updated": "2021-09-21",
        "certification_date": "2021-09-21",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "OSSIE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CASHIER/BILLING SUPERVISOR",
        "authorized_official_telephone_number": "870-295-5225",
        "authorized_official_name_prefix": "Miss"
    },
    "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": "117597749",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP PTAN",
            "identifier": "5G122",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Marianna, AR

Sources for this page

Verify at the official NPI Registry.