NPIMap

Organization Active NPI

Infinity Health

Doing business as Behavioral Health Centers of SO IA - Centerville

  • Federally Qualified Health Center (FQHC)
  • Centerville, IA
National Provider Identifier
1710102132
Registry record updated Feb 11, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
INFINITY HEALTH
Doing business as
Behavioral Health Centers of SO IA - Centerville
Practice address
221 E State St
Centerville, IA 52544-1813
Phone
(641) 856-6471
Fax
(641) 856-2603
NPI assigned
Apr 13, 2007
Last updated
Feb 11, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2022

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

Authorized official

Name
Ms. Samantha Cannon
Title
Ceo
Phone
(641) 446-2383

Specialties & licenses 2

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

Addresses

Primary practice location

221 E State St
Centerville, IA 52544-1813

Mailing address

302 NE 14TH St
Leon, IA 50144-1206
Phone (641) 446-2383

Other identifiers 3

IdentifierTypeStateIssuer
0763805MedicaidIA
39014OtherWELLMARK BLUE CROSS/BLUE SHIELD
507402808MedicaidMO

Other names 1

  • Behavioral Health Centers of SO IA - Centerville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20051024000374 IA Part B Supplier - Clinic/Group Practice 5597717496 Receives reassigned benefits from 27 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Albia, IA; Centerville, IA; Chariton, IA; Corydon, IA; Knoxville, IA; Lamoni, IA; Leon, IA; Mount Ayr, IA…
O20061204000315 IA Part A Provider - Federally Qualified Health Center (FQHC) 5597717496 1 other NPI on this enrollment
Practice locations: Centerville, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1710102132. Details of each certification follow.

Federally qualified health center certification: CCN 161840

Legal name
INFINITY HEALTH
Doing business as
BEHAVIORAL HEALTH CENTERS OF SOUTHERN IOWA
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 6, 2006
Last certification
Dec 6, 2006
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 2005 in IA
Enrollment address
221E State St
Centerville, IA 52544-1813

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 9

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

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
16D1080666Infinity Health221 East State Street, Centerville, IA 52544Certificate of waiverFeb 26, 2028

National Provider Directory

National Provider Directory
Tax ID family
Infinity Health13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

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
Justin James Akers Individual Corporate DirectorBoard Treasurer Aug 22, 2017 10%
Rachel Cecil Individual Corporate Director Mar 26, 2019 10%
Shirley Kessel Individual Corporate DirectorBoard Chair Jan 1, 2005 10%
Jonathan Erb Individual Corporate Director Sep 24, 2019 10%
Alan Wilson Individual Corporate Director Mar 23, 2010 10%
William Morain Individual Corporate DirectorBoard Secretary Jan 1, 2005 10%
Samantha Cannon Individual Corporate OfficerCeo Nov 27, 2012
Corporate DirectorCeo Nov 27, 2012
W-2 Managing EmployeeCeo Nov 27, 2012
Marcy Biesemeyer Individual Corporate Director Apr 22, 2014 10%
Dien Judge Individual Corporate Director Oct 28, 2014 10%
Linda Baynes Individual Corporate DirectorVice Chair May 22, 2018 10%
Alan Dykens Individual Corporate Director Jan 24, 2017 10%

Practitioners & affiliated clinicians

Practitioners 3

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": "1176422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644537600000",
    "number": "1710102132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "302 NE 14TH ST",
            "city": "LEON",
            "state": "IA",
            "postal_code": "501441206",
            "telephone_number": "641-446-2383",
            "fax_number": "641-446-2382"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "221 E STATE ST",
            "city": "CENTERVILLE",
            "state": "IA",
            "postal_code": "525441813",
            "telephone_number": "641-856-6471",
            "fax_number": "641-856-2603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INFINITY HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-13",
        "last_updated": "2022-02-11",
        "certification_date": "2022-02-11",
        "status": "A",
        "authorized_official_last_name": "CANNON",
        "authorized_official_first_name": "SAMANTHA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "641-446-2383",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IA",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0763805",
            "state": "IA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLMARK BLUE CROSS/BLUE SHIELD",
            "identifier": "39014",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "507402808",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Behavioral Health Centers of SO IA - Centerville",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Behavioral Health Centers of SO IA - Centerville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Centerville, IA

Sources for this page

Verify at the official NPI Registry.