NPIMap

Organization Active NPI

Park Duvalle Community Health Center, Inc

Doing business as Henry County Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Eminence, KY
National Provider Identifier
1851957252
Registry record updated Aug 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Doing business as
Henry County Community Health Center
Practice address
500 W Broadway St
Eminence, KY 40019-1201
Phone
(502) 772-5034
NPI assigned
May 13, 2019
Last updated
Aug 1, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
PARK DUVALLE COMMUNITY HEALTH CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 1, 2023

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

Authorized official

Name
Swannie Jett
Title
Ceo
Phone
(502) 774-4401

Specialties & licenses 1

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

Addresses

Primary practice location

500 W Broadway St
Eminence, KY 40019-1201

Mailing address

3015 Wilson Ave
Louisville, KY 40211-1969
Phone (502) 774-4401

Other identifiers 2

IdentifierTypeStateIssuer
31000011MedicaidKY
31000920MedicaidKY

Other names 1

  • Henry County Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040302000539 KY Part B Supplier - Clinic/Group Practice 1658268974 Receives reassigned benefits from 32 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Eminence, KY; Louisville, KY; Taylorsville, KY
O20200310000057 KY Part A Provider - Federally Qualified Health Center (FQHC) 1658268974 Practice locations: Eminence, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851957252. Details of each certification follow.

Federally qualified health center certification: CCN 181191

Legal name
PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 11, 2020
Last certification
Mar 11, 2020
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Mar 30, 1969 in KY
Enrollment address
500 W Broadway St
Eminence, KY 40019-1201

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 7

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

National Provider Directory

National Provider Directory
Tax ID family
Park Duvalle Community Health Center Inc9 organizations share this tax ID, including this one
Part of
Park Duvalle Community Health Center Inc

Other organizations with this tax ID 8

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

Locations

75 Park Rd
#1
New Castle, KY 40050

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Darrell L Shaw Individual Corporate DirectorBoard Member Chair Person Aug 1, 2019
William Holden Individual Corporate DirectorBoard Member Jan 1, 2022
Stacy Sowell Individual Corporate DirectorBoard Member Jan 1, 2022
Desmond L Robinson Individual Corporate DirectorBoard Member Treasurer Aug 1, 2019
Katie Calloway Individual Corporate DirectorBoard Member Aug 1, 2019
Swannie Jett Individual Corporate OfficerCeo Nov 1, 2021
Corporate DirectorCeo Nov 1, 2021
W-2 Managing EmployeeCeo Nov 1, 2021
Operational/Managerial ControlCeo Nov 1, 2021
Barbara Mitchell Individual Corporate DirectorBoard Member Aug 1, 2019
Kevin Bruce Individual Corporate DirectorBoard Member Aug 1, 2019
Angela Wilson Individual Corporate DirectorBoard Member Secretary Aug 1, 2019
Deborah E Thomas Individual Corporate DirectorBoard Member Vice Chair Person Aug 1, 2019
Dwayne Compton Individual Corporate DirectorBoard Member Aug 1, 2019
Martin Tucker Individual Corporate DirectorBoard Member Aug 1, 2019

Practitioners & affiliated clinicians

Practitioners 5

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": "1557705600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690848000000",
    "number": "1851957252",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3015 WILSON AVE",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402111969",
            "telephone_number": "502-774-4401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 W BROADWAY ST",
            "city": "EMINENCE",
            "state": "KY",
            "postal_code": "400191201",
            "telephone_number": "502-772-5034"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PARK DUVALLE COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PARK DUVALLE COMMUNITY HEALTH CENTER, INC",
        "enumeration_date": "2019-05-13",
        "last_updated": "2023-08-01",
        "certification_date": "2023-08-01",
        "status": "A",
        "authorized_official_last_name": "JETT",
        "authorized_official_first_name": "SWANNIE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "502-774-4401"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31000011",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31000920",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Henry County Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Henry County Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Eminence, KY

Sources for this page

Verify at the official NPI Registry.