Clover Fork Outpatient Medical Project Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Evarts, KY
NPI 1811939366 · NPPES record last updated Nov 19, 2018
Key facts
- NPI
- 1811939366
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
- Practice address
- 101 Chad St
Clover Fork Clinic
Evarts, KY 40828-8200 - Phone
- (606) 837-2108
- Fax
- (606) 837-9389
- NPI assigned
- Jun 11, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. Britt Lewis Jr.
- Title
- Administrator
- Phone
- (606) 837-2108
Other NPIs with the same Medicare PAC ID 1
Member of 1
Practitioners 6
-
Sharon M Colton, MD
-
Michael W Napier, PAC
-
Kristen Marie Nash, D.O., M.P.H.
-
Eric N Roberts, PAC
-
Jessica Nichole Turner, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Federally qualified health center certification: CCN 181078
- Legal name
- CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
- Doing business as
- CLOVER FORK CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 22, 2018
- Last certification
- Jan 22, 2018
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 12, 1970 in KY
- Enrollment address
- 101 Chad St
Evarts, KY 40828-8200
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Bobbie Dixon |
Corporate Director |
May 23, 2016 | 10% |
| Eugene Enix |
Corporate Director |
Aug 28, 2023 | 10% |
| Jack Miniard |
Corporate Officer |
Aug 31, 2015 | 50% |
| W-2 Managing Employee |
Aug 31, 2015 | ||
| Claude W Collett |
Corporate Director |
Jun 3, 2013 | 10% |
| John Henson |
Corporate Director |
Mar 29, 2021 | 10% |
| Barry Martin |
Corporate Director |
Jan 31, 2014 | 10% |
| Sonja Lawson |
Corporate Director |
Jan 1, 2001 | 10% |
| Jerry Haynes |
Corporate Director |
Apr 26, 2021 | 10% |
| Tammie Chapman |
Corporate Director |
Aug 28, 2023 | 10% |
| Kim Brown |
Corporate Director |
Mar 28, 2016 | 10% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040126000246 | KY | Part B Supplier - Clinic/Group Practice | 2062317027 |
Receives reassigned benefits from 6 practitioners Practice locations: Evarts, KY |
| O20180122003211 | KY | Part a Provider - Federally Qualified Health Center (FQHC) | 2062317027 | Practice locations: Evarts, KY |
National Provider Directory
Locations
4000 N US Highway 119
Baxter, KY 40806
Phone (606) 573-3006
119 Central St
Cumberland, KY 40823
322 Golf Course Rd
Cumberland, KY 40823
Phone (606) 589-2511
132 Keister St
Evarts, KY 40828
Phone (606) 837-2386
1555 Highway 215
Evarts, KY 40828
121 E Central St
Harlan, KY 40831
Phone (606) 573-1975
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | KY | Yes | |
| Primary Care Clinic/Center | 261QP2300X | 700006 | KY | |
| Rural Health Clinic/Center | 261QR1300X |
Addresses
Primary practice location
101 Chad St
Clover Fork Clinic
Evarts, KY 40828-8200
Mailing address
101 Chad St
PO Box39
Evarts, KY 40828-8200
Phone (606) 837-2108
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 31000045 | Medicaid | KY | |
| 7100323670 | Medicaid | KY |
Other providers in Evarts, KY
- Guadalupe Blas III
- Melanie Buchanan-Manning
- Clover Fork Outpatient Medical Project Inc
- Sharon M Colton
- Cumberland Valley Dist. Health Dept.
- Discreet Therapy Services LLC.
- Rachel R Eubank
- Barbara Kaye Middleton
All providers in Evarts, KY · Federally Qualified Health Center (FQHC) in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 19, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.