NPIMap

Organization Active NPI

Mountain Comprehensive Care Center, Inc.

Doing business as Homeplace Clinic Cynthiana

  • Federally Qualified Health Center (FQHC)
  • Cynthiana, KY
National Provider Identifier
1770121972
Registry record updated Dec 18, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Doing business as
Homeplace Clinic Cynthiana
Practice address
210 S Walnut St
Cynthiana, KY 41031-1541
Phone
(606) 886-8572
Fax
(606) 886-4433
NPI assigned
Dec 18, 2019
Last updated
Dec 18, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 18, 2019

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

Authorized official

Name
Roxann Cordial
Title
Credentialing
Phone
(606) 886-8572

Specialties & licenses 1

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

Addresses

Primary practice location

210 S Walnut St
Cynthiana, KY 41031-1541

Mailing address

210 S Walnut St
Cynthiana, KY 41031-1541
Phone (606) 886-8572

Other names 1

  • Homeplace Clinic Cynthiana Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040416000380 KY Part B Supplier - Clinic/Group Practice 5294720553 Receives reassigned benefits from 237 practitioners
24 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Paintsville, KY; Pikeville, KY; Prestonsburg, KY; Salyersville, KY; Winchester, KY; Martin, KY; Ashland, KY; Belfry, KY…
O20200415001362 KY Part A Provider - Federally Qualified Health Center (FQHC) 5294720553 Practice locations: Cynthiana, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770121972. Details of each certification follow.

Federally qualified health center certification: CCN 181198

Legal name
MOUNTAIN COMPREHENSIVE CARE CENTER INC
Doing business as
HOMEPLACE CLINIC CYNTHIANA
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 10, 2020
Last certification
Apr 10, 2020
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
May 17, 1966 in KY
Enrollment address
210 S Walnut St
Cynthiana, KY 41031-1541

Other NPIs with the same Medicare PAC ID 24

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

View all 24

Other NPIs on the same Medicare enrollment 24

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

View all 24

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
18D2176720Mountain Comprehensive Care Center -210 South Walnut Street, Cynthiana, KY 41031Certificate of waiverDec 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mountain Comprehensive Ca44 organizations share this tax ID, including this one

Other organizations with this tax ID 43

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

View all 43

Locations

145 Vine St
Benton, KY 42025
Phone (270) 527-2273

210 S Walnut St
Cynthiana, KY 41031
Phone (859) 298-2011

217 S Main St
Cynthiana, KY 41031
Phone (859) 358-2051

32 Professional Park Dr
Ste 108
Louisa, KY 41230
Phone (606) 638-4656

838 S Mayo Trl
Paintsville, KY 41240
Phone (606) 788-1345

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Jim Vanover Individual Corporate OfficerChair Jan 1, 2016
Sara Daniels Individual Corporate OfficerBoard Member Jan 1, 2014
Ancil W Lewis Individual Corporate OfficerBoard Member Jan 1, 2017
Lynette Schindler Individual Corporate OfficerBoard Member Jan 1, 2017
Jackie Tackett Individual Corporate OfficerBoard Member Jan 1, 2017
Durward E Hale Individual Corporate OfficerBoard Member Jan 1, 2017
Charles Branham Individual Corporate OfficerBoard Member Jan 1, 2019
Paula Thompson Individual Corporate OfficerBoard Member Jan 1, 2014
Teresa Petot Individual Corporate OfficerBoard Member Jan 1, 2017
Shirley Ratcliff Individual Corporate OfficerBoard Member Jan 1, 2015
Amanda Looney Individual W-2 Managing EmployeeFinancial Manager Dec 6, 2025
Promod Bishnoi Individual Corporate OfficerCeo Jul 31, 2008
Corporate DirectorDirector Jul 31, 2008

Practitioners & affiliated clinicians

Practitioners 46

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 46

NPI Registry JSON

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

{
    "created_epoch": "1576627200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576627200000",
    "number": "1770121972",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "210 S WALNUT ST",
            "city": "CYNTHIANA",
            "state": "KY",
            "postal_code": "410311541",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "210 S WALNUT ST",
            "city": "CYNTHIANA",
            "state": "KY",
            "postal_code": "410311541",
            "telephone_number": "606-886-8572",
            "fax_number": "606-886-4433"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN COMPREHENSIVE CARE CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-18",
        "last_updated": "2019-12-18",
        "certification_date": "2019-12-18",
        "status": "A",
        "authorized_official_last_name": "CORDIAL",
        "authorized_official_first_name": "ROXANN",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "606-886-8572"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Homeplace Clinic Cynthiana",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cynthiana, KY

Sources for this page

Verify at the official NPI Registry.