NPIMap

Organization Active NPI

Diversity Health Center Inc

  • Federally Qualified Health Center (FQHC)
  • Hinesville, GA
National Provider Identifier
1720108590
Registry record updated Jun 12, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
DIVERSITY HEALTH CENTER INC
Practice address
303 Fraser Dr
Hinesville, GA 31313
Phone
(912) 877-2227
Fax
(912) 877-2332
NPI assigned
Mar 29, 2007
Last updated
Jun 12, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2018

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

Authorized official

Name
Stephanie Jones-Theaker
Title
Ceo
Phone
(912) 318-3947

Specialties & licenses 1

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

Addresses

Primary practice location

303 Fraser Dr
Hinesville, GA 31313

Mailing address

PO Box 1520
Hinesville, GA 31310-8520
Phone (912) 877-2227

Other identifiers 1

IdentifierTypeStateIssuer
179704037AMedicaidGA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110810000508 GA Part B Supplier - Clinic/Group Practice 9638261910 Receives reassigned benefits from 26 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Hinesville, GA; Jesup, GA; Ludowici, GA
O20130429000643 GA Part A Provider - Federally Qualified Health Center (FQHC) 9638261910 Practice locations: Hinesville, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720108590. Details of each certification follow.

Federally qualified health center certification: CCN 111926

Legal name
DIVERSITY HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 1, 2009
Last certification
Dec 1, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 6, 2006 in GA
Enrollment address
303 Fraser Dr
Hinesville, GA 31313-3712

Other NPIs with the same Medicare PAC ID 7

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

Locations

213 N McDonald St
Ste A
Ludowici, GA 31316

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
Paulette Robertson Individual Corporate DirectorBoard of Directors Feb 4, 2019 12.5%
Herman Scott Individual Corporate DirectorBoard of Directors Feb 4, 2019 12.5%
Stephanie Jones-Theaker Individual Corporate Officer Jun 1, 2015
Connie Thrift Individual Corporate DirectorBoard of Directors Feb 4, 2019 12.5%
Pepper Renee Wilson Individual W-2 Managing EmployeeBilling Manager Oct 17, 2011
Juanita Smith Individual Corporate DirectorBoard of Directors Jun 1, 2021 10%
Daisy Jones Individual Corporate Director Jun 1, 2021 10%
Brigette Cabeza-Shanken Individual Corporate Director Jun 1, 2021 10%
Janelle Johns Individual Corporate Director Jun 1, 2022 10%
Gwendolyn Stewart Individual Corporate DirectorBoard of Directors Feb 4, 2019 12.5%
Justin Zieman Individual Corporate DirectorBoard of Directors Feb 4, 2019 12.5%

Practitioners & affiliated clinicians

Practitioners 22

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.

View all 22

NPI Registry JSON

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

{
    "created_epoch": "1175126400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1528761600000",
    "number": "1720108590",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1520",
            "city": "HINESVILLE",
            "state": "GA",
            "postal_code": "313108520",
            "telephone_number": "912-877-2227",
            "fax_number": "912-877-2332"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "303 FRASER DR",
            "city": "HINESVILLE",
            "state": "GA",
            "postal_code": "31313",
            "telephone_number": "912-877-2227",
            "fax_number": "912-877-2332"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVERSITY HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-29",
        "last_updated": "2018-06-12",
        "status": "A",
        "authorized_official_last_name": "JONES-THEAKER",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "912-318-3947"
    },
    "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": "179704037A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hinesville, GA

Sources for this page

Verify at the official NPI Registry.