NPIMap

Organization Active NPI

Lake Fork Health Services District

Doing business as Lake City Area Medical Center

  • Rural Health Clinic/Center
  • Lake City, CO
National Provider Identifier
1790767192
Registry record updated Dec 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LAKE FORK HEALTH SERVICES DISTRICT
Doing business as
Lake City Area Medical Center
Practice address
700 N Henson
Lake City, CO 81235-0999
Phone
(970) 944-2331
Fax
(970) 944-2320
NPI assigned
Nov 19, 2005
Last updated
Dec 3, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 3, 2024

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

Authorized official

Name
Dr. Beuford T Durmon, MDNPI 1053369595
Title
Medical Director
Phone
(970) 944-2331

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X CO
Rural Health Clinic/Center 261QR1300X CO Primary

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 1

IdentifierTypeStateIssuer
66109019MedicaidCO

Other names 1

  • Lake City Area Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790767192. Details of each certification follow.

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
OtherNon-profit
Enrollment address
700 N Henson Street
Lake City, CO 81235-0001

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
06D0644463Lake City Area Medical Center700 N Henson St, Lake City, CO 81235ComplianceJul 31, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Malinda McDonald Individual W-2 Managing EmployeeFront Office Coordinator Nov 1, 2013
Rachel Moore Individual Corporate DirectorExecutive Director Oct 1, 2021
Lake Fork Health Services District Organization, Lake City, CO Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2003 100%
William E Gattis Individual Corporate DirectorMedical Director Sep 10, 2020

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1132358400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1733184000000",
    "number": "1790767192",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 999",
            "city": "LAKE CITY",
            "state": "CO",
            "postal_code": "812350999",
            "telephone_number": "970-944-2331",
            "fax_number": "970-944-2331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 N HENSON",
            "city": "LAKE CITY",
            "state": "CO",
            "postal_code": "812350999",
            "telephone_number": "970-944-2331",
            "fax_number": "970-944-2320"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE FORK HEALTH SERVICES DISTRICT",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-19",
        "last_updated": "2024-12-03",
        "certification_date": "2024-12-03",
        "status": "A",
        "authorized_official_last_name": "DURMON",
        "authorized_official_first_name": "BEUFORD",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "970-944-2331",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "CO",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "CO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "66109019",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake City Area Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake City, CO

Sources for this page

Verify at the official NPI Registry.