NPIMap

Organization Active NPI

Citizens of Lake County for Health Care Inc

Doing business as William B, Acree Clinic

  • Federally Qualified Health Center (FQHC)
  • Ridgely, TN
National Provider Identifier
1851697817
Registry record updated Feb 8, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
6899 Issued in TN
Legal business name
CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC
Doing business as
William B, Acree Clinic
Practice address
130 N Main St
Ridgely, TN 38080-1317
Phone
(731) 264-5518
Fax
(731) 264-6859
NPI assigned
Feb 8, 2011
Last updated
Feb 8, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 8, 2011

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

Authorized official

Name
Mrs. Gayanne Cartwright Williams
Title
Executive Director
Phone
(731) 253-6690

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 6899 TN Primary

Addresses

Primary practice location

130 N Main St
Ridgely, TN 38080-1317

Mailing address

130 North Main Street
Ridgely, TN 38080-1317
Phone (731) 264-5518

Other names 1

  • William B, Acree Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20101123000838 TN Part A Provider - Federally Qualified Health Center (FQHC) 6507052073 1 other NPI on this enrollment
Practice locations: Ridgely, TN
O20110718000034 TN Part B Supplier - Clinic/Group Practice 6507052073 Receives reassigned benefits from 11 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ridgely, TN; Troy, TN; Ripley, TN; Tiptonville, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851697817. Details of each certification follow.

Federally qualified health center certification: CCN 441827

Legal name
CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC
Doing business as
WILLIAM B ACREE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 1, 1992
Last certification
Feb 1, 1992
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
130N Main St
Ridgely, TN 38080-1317

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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
44D0313484William B Acree Health Clinic130 North Main St, Ridgely, TN 38080Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Citizens-Lake Co for HLTH4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Linda Leduke Individual Corporate OfficerBoard of Director Member Jul 1, 2014
Rose Currin Individual Corporate DirectorBoard of Director Member Oct 22, 2010
Peter Keiser Individual Corporate DirectorBoard of Director Member Oct 22, 2010
Deborah Beasley Individual Corporate DirectorBoard of Directors Member Oct 22, 2010
Gayanne C Williams Individual W-2 Managing EmployeeExecutive Director Oct 22, 2010
Amber Isbell Individual W-2 Managing EmployeeFinancial Officer Oct 22, 2010
Linda Cook Individual Corporate DirectorBoard of Directors Member Oct 22, 2010
Amy Watts Individual Corporate DirectorBoard of Director Member Oct 22, 2010
Ozella Garland Individual Corporate DirectorBaord of Director Member Oct 22, 2010

Practitioners & affiliated clinicians

Practitioners 2

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": "1297123200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297123200000",
    "number": "1851697817",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "130 NORTH MAIN STREET",
            "city": "RIDGELY",
            "state": "TN",
            "postal_code": "380801317",
            "telephone_number": "731-264-5518",
            "fax_number": "731-264-6859"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "130 N MAIN ST",
            "city": "RIDGELY",
            "state": "TN",
            "postal_code": "380801317",
            "telephone_number": "731-264-5518",
            "fax_number": "731-264-6859"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CITIZENS OF LAKE COUNTY FOR HEALTH CARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-08",
        "last_updated": "2011-02-08",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "GAYANNE",
        "authorized_official_middle_name": "CARTWRIGHT",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "731-253-6690",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "TN",
            "license": "6899",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "William B, Acree Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ridgely, TN

Sources for this page

Verify at the official NPI Registry.