NPIMap

Mountain Comprehensive Care Center, Inc.

Organization Active NPI Federally Qualified Health Center (FQHC) · Martin, KY

NPI 1699456129 · NPPES record last updated Jul 27, 2023

Key facts

NPI
1699456129
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Practice address
263 Ky Route 122
Martin, KY 41649-9006
Phone
(606) 886-8572
Fax
(606) 886-4433
NPI assigned
Jul 27, 2023
Organization subpart
No

Authorized official

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

Other NPIs on the same Medicare enrollment 24

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

Other NPIs with the same Medicare PAC ID 24

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

Corporate family (same tax ID) 43

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

View all 43

Practitioners 88

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 88

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here 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 41649		Certificate of waiverSep 29, 2027

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in KY

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
Corporation · Non-profit
Incorporated
May 17, 1966 in KY
Enrollment address
263 Ky Route 122
Martin, KY 41649-9006

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 Officer
Board Member		 Jan 1, 2017
Ancil W Lewis
Individual 		Corporate Officer
Vice Chair		 Jan 1, 2017
Roy Conley
Individual 		Corporate Officer
Board Member		 Jan 1, 2016
Lynette Schindler
Individual 		Corporate Officer
Board Member		 Jan 1, 2017
Jackie Tackett
Individual 		Corporate Officer
Treasurer		 Jan 1, 2017
Durward E Hale
Individual 		Corporate Officer
Board Member		 Jan 1, 2017
Charles Branham
Individual 		Corporate Officer
Chair		 Jan 1, 2019
Teresa Petot
Individual 		Corporate Officer
Board Member		 Jan 1, 2018
Amanda Looney
Individual 		W-2 Managing Employee
Financial Manager		 Dec 6, 2025
Promod Bishnoi
Individual 		5% Or Greater Indirect Ownership Interest
Ceo		 Jul 31, 2008
Corporate Officer
Ceo		 Jul 31, 2008
Corporate Director
Ceo		 Jul 31, 2008

Medicare enrollment records

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

National Provider Directory

Tax ID family
Mountain Comprehensive Ca (44 organizations share this tax ID)

Locations

263 Ky Route 122
Martin, KY 41649
Phone (606) 949-1555

Specialties & licenses

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

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

  • Homeplace Clinic Martin Doing business as

Other providers in Martin, KY

All providers in Martin, KY · Federally Qualified Health Center (FQHC) in Kentucky

Sources for this page

Verify at the official NPI Registry.