NPIMap

Organization Active NPI

Kiamichi Family Medical Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Broken Bow, OK
National Provider Identifier
1780172916
Registry record updated Apr 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
KIAMICHI FAMILY MEDICAL CENTER, INC
Practice address
510 S Park Dr
Broken Bow, OK 74728-5330
Phone
(580) 241-5294
NPI assigned
Apr 24, 2018
Last updated
Apr 26, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 26, 2018

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

Authorized official

Name
Amy Gilbreath
Title
Ceo
Phone
(580) 241-5294

Specialties & licenses 1

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

Addresses

Primary practice location

510 S Park Dr
Broken Bow, OK 74728-5330

Mailing address

6026 Battiest Pickens Rd
Broken Bow, OK 74728-5033
Phone (580) 241-5294

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180724001230 OK Part A Provider - Federally Qualified Health Center (FQHC) 7315855541 Practice locations: Broken Bow, OK
O20181127003118 OK Part B Supplier - Clinic/Group Practice 7315855541 Receives reassigned benefits from 8 practitioners
Practice locations: Broken Bow, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780172916. Details of each certification follow.

Federally qualified health center certification: CCN 371934

Legal name
KIAMICHI FAMILY MEDICAL CENTER INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 24, 2018
Last certification
Jul 24, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 8, 2002 in OK
Enrollment address
510 S Park Dr
Broken Bow, OK 74728-5330

Other NPIs with the same Medicare PAC ID 3

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

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
37D2149537Kiamichi Family Medical Center, Inc510 S Park Drive, Broken Bow, OK 74728Certificate of waiverJun 4, 2028

National Provider Directory

National Provider Directory

Locations

204 E Jackson St
Hugo, OK 74743
Phone (580) 326-9555

2809 NE Lincoln Rd
Idabel, OK 74745
Phone (580) 286-6688

403 S Indian Rd
Idabel, OK 74745
Phone (580) 286-6688

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/GDGBBA

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
Austin Lindley Individual Corporate Officer Oct 18, 2017
Garrett Tipton Individual Corporate Officer Oct 18, 2017
Micheal McConnell Individual Corporate Officer May 1, 2004
Deborah Farley Individual Corporate Officer Sep 1, 2005
Patty Skeen Individual Corporate Officer Nov 1, 2006
Scott Rickey Individual Corporate DirectorChief Financial Officer Jun 1, 2011
W-2 Managing Employee Jun 1, 2011
Kenneth Dial Individual Corporate Officer Mar 1, 2010
Stacey Ebert Individual Corporate OfficerTreasurer Jun 18, 2014
James Hamilton Individual Corporate Officer Oct 1, 2005
Amy Gilbreath Individual Corporate DirectorChief Executive Officer Jun 1, 2011
W-2 Managing Employee Jun 1, 2011
Operational/Managerial Control Jun 1, 2011
Marla Reynolds Individual Corporate Officer Oct 18, 2017

Practitioners & affiliated clinicians

Practitioners 14

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 14

NPI Registry JSON

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

{
    "created_epoch": "1524528000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1524700800000",
    "number": "1780172916",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6026 BATTIEST PICKENS RD",
            "city": "BROKEN BOW",
            "state": "OK",
            "postal_code": "747285033",
            "telephone_number": "580-241-5294",
            "fax_number": "580-447-2908"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "510 S PARK DR",
            "city": "BROKEN BOW",
            "state": "OK",
            "postal_code": "747285330",
            "telephone_number": "580-241-5294"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KIAMICHI FAMILY MEDICAL CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-04-24",
        "last_updated": "2018-04-26",
        "status": "A",
        "authorized_official_last_name": "GILBREATH",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "580-241-5294"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Broken Bow, OK

Sources for this page

Verify at the official NPI Registry.