Palmetto Health Council Inc

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

License

H800040 Issued in GA

Legal business name

PALMETTO HEALTH COUNCIL INC

Doing business as

Community Medical Center
YourTown Health

Practice address

643 Main St
Palmetto, GA 30268-1138

Phone

(404) 929-8824

Fax

(404) 929-9769

NPI assigned

Sep 29, 2006

Last updated

Sep 10, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Jon William Wollenzien Jr., DBA

Title

Chief Executive Officer

Phone

(404) 929-8824

Specialties & licenses 2

Addresses

Other identifiers 7

Other names 2

• Community Medical Center Doing business as
• YourTown Health Doing business as

Medicare fee-for-service enrollment

Enrolled in GA4 enrollments

Enrollment records 4

NPI to CCN mapping 4

The Medicare certification numbers (CCNs) connected to NPI 1740372473. Details of each certification follow.

• CCN 111818 Federally qualified health center · Terminated · Details
• CCN 111819 Federally qualified health center · Terminated · Details
• CCN 111823 Federally qualified health center · Active · Details
• CCN 111903 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN 111818

Legal name

PALMETTO HEALTH COUNCIL INC

Doing business as

YOURTOWN HEALTH

Certification status

Terminated Voluntary: merger or closure, Jun 1, 1996

Provider type (POS)

Federally qualified health center

Participating since

Oct 1, 1991

Last certification

Oct 1, 1991

Ownership / control type

For profit – partnership

Organization structure

CorporationNon-profit

Incorporated

Jun 1, 1978 in GA

Enrollment address

16201 Barnesville St
Zebulon, GA 30295-3380

Federally qualified health center certification: CCN 111819

Legal name

PALMETTO HEALTH COUNCIL INC

Doing business as

YOURTOWN HEALTH

Certification status

Terminated Voluntary: merger or closure, Jun 1, 1996

Provider type (POS)

Federally qualified health center

Participating since

Oct 1, 1991

Last certification

Oct 1, 1991

Ownership / control type

For profit – partnership

Organization structure

CorporationNon-profit

Incorporated

Jun 1, 1978 in GA

Enrollment address

101 Commerce PL
Ste 1
Barnesville, GA 30204-1680

Federally qualified health center certification: CCN 111823

Legal name

PALMETTO HEALTH COUNCIL INC

Doing business as

YOURTOWN HEALTH

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

Jun 1, 1978 in GA

Enrollment address

643 Main St
Palmetto, GA 30268-1138

Federally qualified health center certification: CCN 111903

Legal name

PALMETTO HEALTH COUNCIL INC

Doing business as

COMMUNITY MEDICAL CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Feb 14, 2008

Last certification

Feb 14, 2008

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Incorporated

Jun 1, 1978 in GA

Enrollment address

202 Croft St
Carrollton, GA 30117-3803

Other NPIs on the same Medicare enrollment 4

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

• Palmetto Health Council Inc

  dba Community Medical Center

  • Federally Qualified Health Center (FQHC)
  • Zebulon, GA
  • NPI 1134344732

  O20050916000963

  Same enrollment
• Palmetto Health Council Inc

  dba YourTown Health

  • Federally Qualified Health Center (FQHC)
  • Barnesville, GA
  • NPI 1164682662

  O20050919000671

  Same enrollment
• Palmetto Health Council Inc

  dba Community Medical Center

  • Federally Qualified Health Center (FQHC)
  • Palmetto, GA
  • NPI 1184884678

  O20050919000940

  Same enrollment
• Palmetto Health Council Inc

  dba YourTown Health

  • Federally Qualified Health Center (FQHC)
  • Carrollton, GA
  • NPI 1467612952

  O20080214000012

  Same enrollment

All disclosed owners & managing parties 17

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

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

{
    "created_epoch": "1159488000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631232000000",
    "number": "1740372473",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "643 MAIN ST",
            "city": "PALMETTO",
            "state": "GA",
            "postal_code": "302681138",
            "telephone_number": "404-929-8824",
            "fax_number": "404-929-9769"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "643 MAIN ST",
            "city": "PALMETTO",
            "state": "GA",
            "postal_code": "302681138",
            "telephone_number": "404-929-8824",
            "fax_number": "404-929-9769"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PALMETTO HEALTH COUNCIL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-29",
        "last_updated": "2021-09-10",
        "certification_date": "2021-09-10",
        "status": "A",
        "authorized_official_last_name": "WOLLENZIEN",
        "authorized_official_first_name": "JON",
        "authorized_official_middle_name": "WILLIAM",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "404-929-8824",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "DBA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "GA",
            "license": "H800040",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "H800040",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "931512872A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000472128F",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000472128A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000472128E",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000472128H",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000228379A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000472128G",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Medical Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "YourTown Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Nra-Palmetto, Georgia, LLC (Palmetto Dialysis Clinic)
• Daniell Odionesene, OT
• Palmetto Family Dental, PC
• Palmetto Health Council Inc (Community Medical Center)
• Palmetto Health Council Inc (Palmetto Health Council Pharmacy)
• Palmetto Health Council, Inc. (YourTownHealth)
• Palmetto Sleep PC
• Palmetto Sleep, PC
• Gabriela Pena, M.D.
• Alanna Perlin, MD

• Federally Qualified Health Center (FQHC) in Palmetto, GA
• Providers in Palmetto, GA by specialty
• Federally Qualified Health Center (FQHC) in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.