NPIMap

Organization Active NPI

Humboldt Family Walk-in Clinic LLC

  • Rural Health Clinic/Center
  • Humboldt, TN
National Provider Identifier
1881135895
Registry record updated Dec 9, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
HUMBOLDT FAMILY WALK-IN CLINIC LLC
Practice address
1600 Coleman Dr
Humboldt, TN 38343-1756
Phone
(731) 470-4020
Fax
(731) 562-0349
NPI assigned
Mar 10, 2017
Last updated
Dec 9, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 9, 2019

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

Authorized official

Name
Deborah L Graves, MSNNPI 1841404035
Title
Owner
Phone
(731) 470-4020

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

1600 Coleman Dr
Humboldt, TN 38343-1756

Mailing address

1600 Coleman Dr
Humboldt, TN 38343-0068
Phone (731) 470-4020

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170810003221 TN Part B Supplier - Clinic/Group Practice 3072899434 Receives reassigned benefits from 5 practitioners
Practice locations: Humboldt, TN
O20200909003204 TN Part A Provider - Rural Health Clinic 3072899434 Practice locations: Humboldt, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881135895. Details of each certification follow.

Rural health clinic certification: CCN 883829

Legal name
HUMBOLDT FAMILY WALK-IN CLINIC LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 30, 2020
Last certification
Feb 9, 2026
Ownership / control type
1A
Organization structure
LLCProprietary
Enrollment address
1600 Coleman Dr
Humboldt, TN 38343-1995

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
44D2107298Humboldt Family Walk-in Clinic1600 Coleman Drive, Humboldt, TN 38343ComplianceApr 3, 2027

National Provider Directory

National Provider Directory

Locations

1600 Coleman Dr
Humboldt, TN 38343
Phone (731) 470-4020

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Deborah Graves Individual 5% Or Greater Direct Ownership InterestOwner Apr 16, 2016 100%
Corporate OfficerOwner Apr 16, 2016 100%
Operational/Managerial ControlOwner Apr 16, 2016 100%

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": "1489104000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1575849600000",
    "number": "1881135895",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1600 COLEMAN DR",
            "city": "HUMBOLDT",
            "state": "TN",
            "postal_code": "383430068",
            "telephone_number": "731-470-4020",
            "fax_number": "731-562-0349"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 COLEMAN DR",
            "city": "HUMBOLDT",
            "state": "TN",
            "postal_code": "383431756",
            "telephone_number": "731-470-4020",
            "fax_number": "731-562-0349"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HUMBOLDT FAMILY WALK-IN CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-10",
        "last_updated": "2019-12-09",
        "certification_date": "2019-12-09",
        "status": "A",
        "authorized_official_last_name": "GRAVES",
        "authorized_official_first_name": "DEBORAH",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "731-470-4020",
        "authorized_official_credential": "MSN"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Humboldt, TN

Sources for this page

Verify at the official NPI Registry.