NPIMap

Organization Active NPI

Chicot Memorial Medical Center

  • Medicare Defined Swing Bed Hospital Unit
  • Lake Village, AR
National Provider Identifier
1821313313
Registry record updated Jun 30, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
Legal business name
CHICOT MEMORIAL MEDICAL CENTER
Practice address
2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136
Phone
(870) 265-5351
Fax
(870) 265-2091
NPI assigned
Mar 29, 2010
Last updated
Jun 30, 2015By the provider in NPPES
Organization subpart
Yes
Parent organization
CHICOT MEMORIAL MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 30, 2015

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

Authorized official

Name
Susan Vaughn
Title
Cfo
Phone
(870) 265-5351

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X AR4386 AR
Medicare Defined Swing Bed Hospital Unit 275N00000X NU Primary

Addresses

Primary practice location

2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136

Mailing address

2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136
Phone (870) 265-5351

Other identifiers 1

IdentifierTypeStateIssuer
181080105MedicaidAR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101005000530 AR Part A Provider - Critical Access Hospital 2466576194 Practice locations: Lake Village, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821313313. Details of each certification follow.

Hospital certification: CCN 04Z328

Legal name
CHICOT MEMORIAL MEDICAL CENTER
Organization structure
CorporationNon-profit
Incorporated
Dec 16, 2009 in AR
Enrollment address
2729 S Highway 65 & 82
Lake Village, AR 71653-6136
Other Hospital Practice Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
Chicot Mem Med Ctr5 organizations share this tax ID, including this one
Part of
Chicot Mem Med Ctr

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
John Todd Potter Individual Corporate Director May 1, 2010
Tommy Jarrett Individual Corporate Director May 1, 2010
Vicki Allen Individual Corporate OfficerChief Financial Officer Mar 28, 2023
W-2 Managing EmployeeChief Financial Officer Mar 28, 2023
Linda Thomas Individual Corporate Director May 1, 2010
Mack Ball Individual Corporate Director May 1, 2010
Olan Mencer Individual Corporate Director May 1, 2010
Sam Angel Individual Corporate Director May 1, 2010
John P Burge Individual Corporate Director May 1, 2010

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

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1269820800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1435622400000",
    "number": "1821313313",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2729 HWY 65 & 82 S",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536136",
            "telephone_number": "870-265-5351",
            "fax_number": "870-265-2091"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2729 HWY 65 & 82 S",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536136",
            "telephone_number": "870-265-5351",
            "fax_number": "870-265-2091"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHICOT MEMORIAL MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHICOT MEMORIAL MEDICAL CENTER",
        "enumeration_date": "2010-03-29",
        "last_updated": "2015-06-30",
        "status": "A",
        "authorized_official_last_name": "VAUGHN",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "870-265-5351"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "AR",
            "license": "AR4386",
            "primary": false
        },
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "181080105",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Village, AR

Sources for this page

Verify at the official NPI Registry.