NPIMap

Organization Active NPI

County of Clay

Doing business as Clay County Memorial Hospital

  • Critical Access Hospital Clinic/Center
  • Henrietta, TX
National Provider Identifier
1881175776
Registry record updated Aug 28, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access Hospital Clinic/CenterTaxonomy code 261QC0050X
License
000193 Issued in TX
Legal business name
COUNTY OF CLAY
Doing business as
Clay County Memorial Hospital
Practice address
310 W South St
Henrietta, TX 76365-3346
Phone
(940) 538-5621
Fax
(940) 235-1215
NPI assigned
Aug 28, 2018
Last updated
Aug 28, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 28, 2018

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

Authorized official

Name
Debra Haehn
Title
Cfo
Phone
(940) 538-5621

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital Clinic/Center 261QC0050X 000193 TX Primary

Addresses

Primary practice location

310 W South St
Henrietta, TX 76365-3346

Mailing address

310 W South St
Henrietta, TX 76365-3346
Phone (940) 538-5621

Other names 1

  • Clay County Memorial Hospital Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20061104000371 TX Part A Provider - Critical Access Hospital 4981689783 Receives reassigned benefits from 6 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Henrietta, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881175776. Details of each certification follow.

Hospital certification: CCN 451362

Legal name
COUNTY OF CLAY
Doing business as
CLAY COUNTY MEMORIAL HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Mar 1, 2005
Last certification
Aug 18, 2021
Beds
25
Ownership / control type
Local
Organization structure
GovernmentNon-profit
Enrollment address
310 W South St
Clay County Memorial Hospital
Henrietta, TX 76365-3346

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

Other NPIs on the same Medicare enrollment 2

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Clay County Memorial HospitalCCN 451362 · All quality measures
Type
Critical Access Hospitals
Ownership
Government - Local
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
Clay County Memorial Ho8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Linda Burleson Individual W-2 Managing Employee Oct 28, 2009
County of Clay Organization, Henrietta, TX 5% Or Greater Direct Ownership Interest Oct 28, 2009
Bob Ellzey Individual Corporate DirectorInterim Ceo Jun 1, 2023
James E Koulovatos Individual W-2 Managing EmployeeCeo Dec 4, 2023 100%
Debra Haehn Individual Corporate DirectorCfo Oct 28, 2009
W-2 Managing EmployeeCfo Oct 28, 2009

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • County of Clay

    dba Clay County Memorial Hospital

    • Ambulance
    • Henrietta, TX
    • NPI 1093832784

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • County of Clay

    dba Clay County Memorial Hospital

    • Critical Access Hospital
    • Henrietta, TX
    • NPI 1437156361

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • County of Clay

    dba Clay County Memorial Hospital

    • Medicare Defined Swing Bed Hospital Unit
    • Henrietta, TX
    • NPI 1518023993

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • County of Clay

    dba Clay County Memorial Hospital

    • Surgery Physician
    • Henrietta, TX
    • NPI 1639340748

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • County of Clay

    dba Clay County Home Health Care

    • Home Health Agency
    • Henrietta, TX
    • NPI 1801803267

    5% Or Greater Direct Ownership Interest

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 45

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

View all 45

NPI Registry JSON

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

{
    "created_epoch": "1535414400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1535414400000",
    "number": "1881175776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "310 W SOUTH ST",
            "city": "HENRIETTA",
            "state": "TX",
            "postal_code": "763653346",
            "telephone_number": "940-538-5621",
            "fax_number": "940-235-1215"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "310 W SOUTH ST",
            "city": "HENRIETTA",
            "state": "TX",
            "postal_code": "763653346",
            "telephone_number": "940-538-5621",
            "fax_number": "940-235-1215"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTY OF CLAY",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-08-28",
        "last_updated": "2018-08-28",
        "status": "A",
        "authorized_official_last_name": "HAEHN",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "940-538-5621"
    },
    "taxonomies": [
        {
            "code": "261QC0050X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Critical Access Hospital",
            "state": "TX",
            "license": "000193",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clay County Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Clay County Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Henrietta, TX

Sources for this page

Verify at the official NPI Registry.