NPIMap

Organization Active NPI

Jefferson Comprehensive Care System, Inc

Doing business as Altheimer Center

  • Federally Qualified Health Center (FQHC)
  • Altheimer, AR
National Provider Identifier
1730385105
Registry record updated Jul 20, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Doing business as
Altheimer Center
Practice address
309 S Edline
Altheimer, AR 72004-8559
Phone
(870) 766-8411
Fax
(870) 766-8412
NPI assigned
Jun 22, 2007
Last updated
Jul 20, 2007By the provider in NPPES
Organization subpart
Yes
Parent organization
JEFFERSON COMPREHENSIVE CARE SYSTEM, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 20, 2007

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

Authorized official

Name
Mr. Larnell W Davis
Title
Executive Director
Phone
(870) 543-2380

Specialties & licenses 1

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

Addresses

Primary practice location

309 S Edline
Altheimer, AR 72004-8559

Mailing address

PO Box 1285
Pine Bluff, AR 71613-1285
Phone (870) 543-2380

Other identifiers 1

IdentifierTypeStateIssuer
122651749MedicaidAR

Other names 1

  • Altheimer Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040603001458 AR Part B Supplier - Clinic/Group Practice 5193634509 Receives reassigned benefits from 22 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Altheimer, AR; Redfield, AR; Pine Bluff, AR; North Little Rock, AR; Little Rock, AR; College Station, AR
O20100610000152 AR Part A Provider - Federally Qualified Health Center (FQHC) 5193634509 Practice locations: Altheimer, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1730385105. Details of each certification follow.

Federally qualified health center certification: CCN 041822

Legal name
JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Doing business as
ALTHEIMER CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 28, 1994 in AR
Enrollment address
309S Edline
Altheimer, AR 72004-8559

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 7

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
04D0466080Altheimer Clinic309 South Edline, Altheimer, AR 72004Provider-performed microscopyAug 20, 2027

National Provider Directory

National Provider Directory
Tax ID family
Pine Bluff Health Clinic12 organizations share this tax ID, including this one
Part of
Pine Bluff Health Clinic

Other organizations with this tax ID 11

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

Locations

309 S Edline
Altheimer, AR 72004
Phone (870) 543-2380

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
Lillie Reeves Individual Corporate OfficerBoard Member Feb 16, 2010 1.47%
Belinda Jones Individual Corporate OfficerBoard Member Feb 1, 2010 1.47%
Bonita Corbin Individual Corporate OfficerBoard Member Feb 1, 2010 1.47%
Chanda Evans-McField Individual Corporate DirectorC.F.O. Oct 1, 2010
Albert Lowery Individual Corporate OfficerBoard Member Feb 16, 2010 1.47%
Corporate Director Feb 1, 2010
Sandra J Brown Individual Corporate Director Sep 18, 2012
W-2 Managing Employee Mar 10, 2010
Leila Alston Individual Corporate OfficerBoard Member Feb 1, 2010 1.47%
Thelma Flournoy Individual Corporate OfficerBoard Member Feb 1, 2010 1.47%
Jeremy Lambert Individual Corporate OfficerBoard Member Feb 16, 2010 1.47%
Patricia a Washington Individual Corporate Director May 13, 2013
W-2 Managing Employee May 13, 2013
Stephanie Stanton Individual Corporate OfficerBoard Member Feb 16, 2010 1.47%

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Downtown Little Rock Community Health CenterLittle Rock, AR, CCN 041055 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 30, 1972
Jefferson Comprehensive Care System, IncLittle Rock, AR, CCN 041051 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 30, 1972

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 4

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": "1182470400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1184889600000",
    "number": "1730385105",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1285",
            "city": "PINE BLUFF",
            "state": "AR",
            "postal_code": "716131285",
            "telephone_number": "870-543-2380",
            "fax_number": "870-535-4716"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "309 S EDLINE",
            "city": "ALTHEIMER",
            "state": "AR",
            "postal_code": "720048559",
            "telephone_number": "870-766-8411",
            "fax_number": "870-766-8412"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON COMPREHENSIVE CARE SYSTEM, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "JEFFERSON COMPREHENSIVE CARE SYSTEM, INC",
        "enumeration_date": "2007-06-22",
        "last_updated": "2007-07-20",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "LARNELL",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "870-543-2380",
        "authorized_official_name_prefix": "Mr."
    },
    "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": "122651749",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Altheimer Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Altheimer, AR

Sources for this page

Verify at the official NPI Registry.