NPIMap

Organization Active NPI

Mountain Comprehensive Care Center, Inc.

Doing business as Homeplace Clinic Martin

  • Federally Qualified Health Center (FQHC)
  • Martin, KY
National Provider Identifier
1699456129
Registry record updated Jul 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Doing business as
Homeplace Clinic Martin
Practice address
263 Ky Route 122
Martin, KY 41649-9006
Phone
(606) 886-8572
Fax
(606) 886-4433
NPI assigned
Jul 27, 2023
Last updated
Jul 27, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 27, 2023

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

Authorized official

Name
Roxann Cordial
Title
Credentialing Manager
Phone
(606) 886-8572

Specialties & licenses 1

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

Addresses

Primary practice location

263 Ky Route 122
Martin, KY 41649-9006

Mailing address

104 S Front Ave
Prestonsburg, KY 41653-1614
Phone (606) 886-8572

Other names 1

  • Homeplace Clinic Martin Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040416000380 KY Part B Supplier - Clinic/Group Practice 5294720553 Receives reassigned benefits from 237 practitioners
24 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Paintsville, KY; Pikeville, KY; Prestonsburg, KY; Salyersville, KY; Winchester, KY; Martin, KY; Ashland, KY; Belfry, KY…
O20240206003210 KY Part A Provider - Federally Qualified Health Center (FQHC) 5294720553 Practice locations: Martin, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699456129. Details of each certification follow.

Federally qualified health center certification: CCN B01125

Legal name
MOUNTAIN COMPREHENSIVE CARE CENTER INC
Doing business as
HOMEPLACE CLINIC MARTIN
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 6, 2024
Last certification
Feb 6, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 17, 1966 in KY
Enrollment address
263 Ky Route 122
Martin, KY 41649-9006

Other NPIs with the same Medicare PAC ID 24

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

View all 24

Other NPIs on the same Medicare enrollment 24

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

View all 24

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
18D2290787Mountain Comprehensive Care Center, Inc -263 Ky Route 122, Martin, KY 41649Certificate of waiverSep 29, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mt Comprehensive Care C48 organizations share this tax ID, including this one

Other organizations with this tax ID 47

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

View all 47

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Sara Daniels Individual Corporate OfficerBoard Member Jan 1, 2017
Ancil W Lewis Individual Corporate OfficerVice Chair Jan 1, 2017
Roy Conley Individual Corporate OfficerBoard Member Jan 1, 2016
Lynette Schindler Individual Corporate OfficerBoard Member Jan 1, 2017
Jackie Tackett Individual Corporate OfficerTreasurer Jan 1, 2017
Durward E Hale Individual Corporate OfficerBoard Member Jan 1, 2017
Charles Branham Individual Corporate OfficerChair Jan 1, 2019
Teresa Petot Individual Corporate OfficerBoard Member Jan 1, 2018
Amanda Looney Individual W-2 Managing EmployeeFinancial Manager Dec 6, 2025
Promod Bishnoi Individual 5% Or Greater Indirect Ownership InterestCeo Jul 31, 2008
Corporate OfficerCeo Jul 31, 2008
Corporate DirectorCeo Jul 31, 2008

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1690416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690416000000",
    "number": "1699456129",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 S FRONT AVE",
            "city": "PRESTONSBURG",
            "state": "KY",
            "postal_code": "416531614",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "263 KY ROUTE 122",
            "city": "MARTIN",
            "state": "KY",
            "postal_code": "416499006",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN COMPREHENSIVE CARE CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-07-27",
        "last_updated": "2023-07-27",
        "certification_date": "2023-07-27",
        "status": "A",
        "authorized_official_last_name": "CORDIAL",
        "authorized_official_first_name": "ROXANN",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "606-886-8572"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Homeplace Clinic Martin",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Martin, KY

Sources for this page

Verify at the official NPI Registry.