NPIMap

Organization Active NPI

Community Hospital Association, Inc.

Doing business as Community Hospital Clinic-Wittmann

  • Rural Health Clinic/Center
  • Wittmann, AZ
National Provider Identifier
1770097123
Registry record updated Nov 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COMMUNITY HOSPITAL ASSOCIATION, INC.
Doing business as
Community Hospital Clinic-Wittmann
Practice address
32919 N Center St Ste B
Wittmann, AZ 85361-9433
Phone
(928) 668-1833
NPI assigned
Nov 21, 2017
Last updated
Nov 21, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY HOSPITAL ASSOCIATION, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 21, 2017

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

Authorized official

Name
James Tavary
Title
Ceo
Phone
(928) 684-5421

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

32919 N Center St Ste B
Wittmann, AZ 85361-9433

Mailing address

523 Rose LN
Wickenburg, AZ 85390-1448
Phone (928) 668-1845

Other names 1

  • Community Hospital Clinic-Wittmann Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040616001475 AZ Part B Supplier - Clinic/Group Practice 4981688900 Receives reassigned benefits from 42 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Wittmann, AZ; Wickenburg, AZ; Congress, AZ; Bagdad, AZ
O20190508001059 AZ Part A Provider - Rural Health Clinic 4981688900 Practice locations: Wittmann, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770097123. Details of each certification follow.

Rural health clinic certification: CCN 038511

Legal name
COMMUNITY HOSPITAL ASSOCIATION INC
Doing business as
COMMUNITY HOSPITAL CLINIC- WITTMANN
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 6, 2018
Last certification
Sep 24, 2021
Ownership / control type
1B
Organization structure
CorporationNon-profit
Incorporated
Aug 21, 1946 in AZ
Enrollment address
32919 N Center St
Ste B
Wittmann, AZ 85361-9433
Related CCNs
031300

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 4

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
03D2140843Community Hospital Clinic - Wittmann32919 Center St, Ste B, Wittmann, AZ 85361Certificate of waiverNov 30, 2027

National Provider Directory

National Provider Directory
Part of
Wickenburg Regional Med

Locations

32919 N Center St
Wittmann, AZ 85361
Phone (928) 668-1833

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Community Hospital Association Inc Organization, Wickenburg, AZ Non-profit Operational/Managerial Control Jun 1, 2017 100%
Jackie Lundblad Individual Corporate OfficerCeo Feb 1, 2002 100%
W-2 Managing Employee Feb 1, 2021 100%

Owners & managing parties with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 29

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 29

NPI Registry JSON

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

{
    "created_epoch": "1511222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1511222400000",
    "number": "1770097123",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "523 ROSE LN",
            "city": "WICKENBURG",
            "state": "AZ",
            "postal_code": "853901448",
            "telephone_number": "928-668-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "32919 N CENTER ST STE B",
            "city": "WITTMANN",
            "state": "AZ",
            "postal_code": "853619433",
            "telephone_number": "928-668-1833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HOSPITAL ASSOCIATION, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY HOSPITAL ASSOCIATION, INC",
        "enumeration_date": "2017-11-21",
        "last_updated": "2017-11-21",
        "status": "A",
        "authorized_official_last_name": "TAVARY",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "928-684-5421"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Hospital Clinic-Wittmann",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wittmann, AZ

Sources for this page

Verify at the official NPI Registry.