NPIMap

Organization Active NPI

Lawrence County Family Clinic, PA

Doing business as Lawence County Family Clinic, P.A .,Rural Health Clinic

  • Rural Health Clinic/Center
  • Walnut Ridge, AR
National Provider Identifier
1740317452
Registry record updated May 15, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LAWRENCE COUNTY FAMILY CLINIC, PA
Doing business as
Lawence County Family Clinic, P.A .,Rural Health Clinic
Practice address
1210 W Main St
Walnut Ridge, AR 72476-1005
Phone
(870) 886-3543
Fax
(870) 886-3252
NPI assigned
Feb 28, 2007
Last updated
May 15, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2014

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

Authorized official

Name
Mrs. Anita B Marlin
Title
Insurance Clerk
Phone
(870) 886-3543

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

1210 W Main St
Walnut Ridge, AR 72476-1005

Mailing address

PO Box 719
Walnut Ridge, AR 72476-0719
Phone (870) 886-3543

Other identifiers 1

IdentifierTypeStateIssuer
128549729MedicaidAR

Other names 1

  • Lawence County Family Clinic, P.A .,Rural Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100330000701 AR Part A Provider - Rural Health Clinic 1557347572 Practice locations: Walnut Ridge, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1740317452. Details of each certification follow.

Rural health clinic certification: CCN 043839

Legal name
LAWRENCE COUNTY FAMILY CLINIC, PA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 26, 1995
Last certification
Jan 10, 2019
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Apr 1, 1974 in AR
Enrollment address
1210 W Main St
Walnut Ridge, AR 72476-1005

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory
Tax ID family
Lawence County Family Clinic PA Rural Health Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Locations

1210 W Main St
Walnut Ridge, AR 72476
Phone (870) 886-3543

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Clay R Spencer Individual 5% Or Greater Direct Ownership Interest Jul 26, 2004
Brandi D Hall Individual W-2 Managing EmployeeAd; Feb 1, 2024
Sebastian a Spades Individual 5% Or Greater Direct Ownership Interest Sep 26, 1995
Cassandra L Hunter Individual 5% Or Greater Direct Ownership InterestMedical Doctor Sep 1, 2017 20%
Charles D Davidson Individual 5% Or Greater Direct Ownership Interest Jul 6, 1999
Corporate Director Jul 6, 1999
Shawn Peyton Individual 5% Or Greater Direct Ownership Interest Jul 14, 1997

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

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": "1172620800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400112000000",
    "number": "1740317452",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 719",
            "city": "WALNUT RIDGE",
            "state": "AR",
            "postal_code": "724760719",
            "telephone_number": "870-886-3543",
            "fax_number": "870-886-3252"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1210 W MAIN ST",
            "city": "WALNUT RIDGE",
            "state": "AR",
            "postal_code": "724761005",
            "telephone_number": "870-886-3543",
            "fax_number": "870-886-3252"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAWRENCE COUNTY FAMILY CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-28",
        "last_updated": "2014-05-15",
        "status": "A",
        "authorized_official_last_name": "MARLIN",
        "authorized_official_first_name": "ANITA",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "INSURANCE CLERK",
        "authorized_official_telephone_number": "870-886-3543",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "128549729",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lawence County Family Clinic, P.A .,Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Walnut Ridge, AR

Sources for this page

Verify at the official NPI Registry.