Lake Fork Health Services District
Organization Active NPI Rural Health Clinic/Center · Lake City, CO
NPI 1790767192 · NPPES record last updated Dec 3, 2024
Key facts
- NPI
- 1790767192
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- LAKE FORK HEALTH SERVICES DISTRICT
- Practice address
- 700 N Henson
Lake City, CO 81235-0999 - Phone
- (970) 944-2331
- Fax
- (970) 944-2320
- NPI assigned
- Nov 19, 2005
- Organization subpart
- No
Authorized official
- Name
- Dr. Beuford T Durmon, MD
- Title
- Medical Director
- Phone
- (970) 944-2331
Owners & managing parties with NPI records 1
Practitioners 7
-
Jessie Reines, FNP
-
Amanda Fender, PA-C
-
Sherry Rae Huisman, FNP-BC
-
Robert K Downs, PA
-
Mallory Parker, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 06D0644463 | Lake City Area Medical Center | Compliance | Jul 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CO
Rural health clinic certification: CCN 063810
- Legal name
- LAKE FORK HEALTH SERVICES DISTRICT
- Doing business as
- LAKE CITY AREA MEDICAL CENTER
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jun 1, 1984
- Last certification
- Apr 2, 2024
- Ownership / control type
- Non-profit – church related
- Most recent change of ownership
- Jan 1, 2003 (1 total)
- Organization structure
- Other · Non-profit
- Enrollment address
- 700 N Henson Street
Lake City, CO 81235-0001
All disclosed owners & managing parties 4
| Name | Role | Since | Share |
|---|---|---|---|
| Malinda McDonald |
W-2 Managing Employee |
Nov 1, 2013 | |
| Rachel Moore |
Corporate Director |
Oct 1, 2021 | |
| Lake Fork Health Services District |
5% Or Greater Direct Ownership Interest | Jan 1, 2003 | 100% |
| William E Gattis |
Corporate Director |
Sep 10, 2020 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20030417000013 | CO | Part a Provider - Rural Health Clinic | 4981513835 | Practice locations: Lake City, CO |
| O20051104000703 | CO | Part B Supplier - Clinic/Group Practice | 4981513835 |
Receives reassigned benefits from 7 practitioners Practice locations: Lake City, CO |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dental Clinic/Center | 261QD0000X | CO | ||
| Rural Health Clinic/Center | 261QR1300X | CO | Yes |
Addresses
Primary practice location
700 N Henson
Lake City, CO 81235-0999
Mailing address
PO Box 999
Lake City, CO 81235-0999
Phone (970) 944-2331
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 66109019 | Medicaid | CO |
Other names
- Lake City Area Medical Center
Other providers in Lake City, CO
- Heights Physical Therapy LLC
- Donna Sue Hudgins
- Sherry Rae Huisman
- Lake City Dental Clinic
- Lake City Dental Clinic
- Roxanne Loper
- Phyllis Mabbett
- Teslin Emory Sky Maclaren
- Robert Noelke
- Silver Thread Public Health District
All providers in Lake City, CO · Rural Health Clinic/Center in Colorado
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 3, 2024. 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.