Kiamichi Family Medical Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Broken Bow, OK
NPI 1780172916 · NPPES record last updated Apr 26, 2018
Key facts
- NPI
- 1780172916
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 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
- Organization subpart
- No
Authorized official
- Name
- Amy Gilbreath
- Title
- Ceo
- Phone
- (580) 241-5294
Other NPIs with the same Medicare PAC ID 3
Practitioners 14
-
Lisa A Baracker, DO
-
Jamie Bivings, LCSW
-
Natorrie D'Atra Morris, APRN
-
John D Lindsey, M.D.
-
David Jordan Paslay, M.D.
-
Tonya Joy Boles, PAC
-
Bambi A Clay, PA-C
-
Beth Lee Leader, DO
-
Tabatha Leforce, APRN
-
Tammy Michelle Williams, PA-C
-
Gordon Butzirus, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 37D2149537 | Kiamichi Family Medical Center, Inc | Certificate of waiver | Jun 4, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in OK
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
- Corporation · Non-profit
- Incorporated
- Jan 8, 2002 in OK
- Enrollment address
- 510 S Park Dr
Broken Bow, OK 74728-5330
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Austin Lindley |
Corporate Officer | Oct 18, 2017 | |
| Garrett Tipton |
Corporate Officer | Oct 18, 2017 | |
| Micheal McConnell |
Corporate Officer | May 1, 2004 | |
| Deborah Farley |
Corporate Officer | Sep 1, 2005 | |
| Patty Skeen |
Corporate Officer | Nov 1, 2006 | |
| Scott Rickey |
Corporate Director |
Jun 1, 2011 | |
| W-2 Managing Employee | Jun 1, 2011 | ||
| Kenneth Dial |
Corporate Officer | Mar 1, 2010 | |
| Stacey Ebert |
Corporate Officer |
Jun 18, 2014 | |
| James Hamilton |
Corporate Officer | Oct 1, 2005 | |
| Amy Gilbreath |
Corporate Director |
Jun 1, 2011 | |
| W-2 Managing Employee | Jun 1, 2011 | ||
| Operational/Managerial Control | Jun 1, 2011 | ||
| Marla Reynolds |
Corporate Officer | Oct 18, 2017 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/GDGBBA
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
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
Other providers in Broken Bow, OK
- Raven Cheyanne James
- Jane M Harmon DNP,RN,Pmhnp-BC,PLLC
- Mykal Jordan
- Kylah Cheyenne Kelly
- Kiamichi Family Medical Center Inc.
- Mark R Lanka
- Tabatha Leforce
- Pamela S Lininger
- Marie Irene Loucks
- Misti D Luke
All providers in Broken Bow, OK · Federally Qualified Health Center (FQHC) in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 26, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.