NPIMap

Organization Active NPI

Family Health Care Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Mize, MS
National Provider Identifier
1881827434
Registry record updated Jul 4, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FAMILY HEALTH CARE CLINIC, INC.
Practice address
125 School Rd
Mize Attendance Center
Mize, MS 39116
Phone
(601) 825-7280
Fax
(601) 825-8130
NPI assigned
Aug 31, 2009
Last updated
Jul 4, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 4, 2018

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

Authorized official

Name
Karina Marie Clayton
Title
Chief Financial Officer
Phone
(601) 825-7280

Specialties & licenses 1

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

Addresses

Primary practice location

125 School Rd
Mize Attendance Center
Mize, MS 39116

Mailing address

PO Box 24116
Jackson, MS 39225-4116
Phone (601) 825-7280

Other identifiers 2

IdentifierTypeStateIssuer
02829320MedicaidMS
251803OtherMSMEDICARE TYPE - UNSPECIFIED

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040831001179 MS Part B Supplier - Clinic/Group Practice 5395656946 Receives reassigned benefits from 71 practitioners
37 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Monticello, MS; Pearl, MS; Newhebron, MS; Pelahatchie, MS; Piney Woods, MS; Pinola, MS; Prentiss, MS; Raleigh, MS…
O20091014000374 MS Part A Provider - Federally Qualified Health Center (FQHC) 5395656946 Practice locations: Mize, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881827434. Details of each certification follow.

Federally qualified health center certification: CCN 251803

Legal name
FAMILY HEALTH CARE CLINIC INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 14, 2009
Last certification
Oct 14, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1996 in MS
Enrollment address
125 School Rd
Mize, MS 39116-5637

Other NPIs on the same Medicare enrollment 37

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

View all 37

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
25D2032524Family Health Care Clinic Inc Mize Attendance Ctr125 School Drive, Mize, MS 39116Certificate of waiverNov 8, 2027

National Provider Directory

National Provider Directory

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
Brenda Blakeslee Individual Corporate DirectorBoard Member Jul 21, 2009
Cierra Hernandez Individual Corporate DirectorBoard Member Jul 21, 2009
Margaret a Gray Individual Corporate DirectorPresident and Ceo Jul 21, 2009
W-2 Managing EmployeePresident and Ceo Jul 21, 2009
Charles Hatten Individual Corporate DirectorBoard Member Jul 21, 2009
Michael Howard Individual Corporate DirectorBoard Member-Treasurer Jul 21, 2009
Helen Johnson Individual Corporate DirectorBoard Member-Vice Chair Jul 21, 2009
Louise Patterson Individual Corporate DirectorBoard Member-Chair Jul 21, 2009
Moses Johnson Individual Corporate DirectorBoard Member-Vice Chair Jul 21, 2009
Carolyn Hartzog Individual Corporate DirectorBoard Member Jul 21, 2009
Lydia Gonzalez-Seals Individual Corporate DirectorBoard Member-Officer Jul 21, 2009
Cindy Bryan Individual Corporate DirectorBoard Member Jul 21, 2009
Eddie Thames Individual Corporate DirectorBoard Member Jul 21, 2009

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Family Health Care Clinic IncRussellville, AL, CCN 011965 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncMuscle Shoals, AL, CCN 011970 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncDecatur, AL, CCN 011967 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncTown Creek, AL, CCN 011966 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncFlorence, AL, CCN 011969 Federally qualified health center Operational/Managerial Control Aug 1, 2009
Family Health Care Clinic IncRogersville, AL, CCN 011971 Federally qualified health center Operational/Managerial Control Aug 1, 2009

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.

NPI Registry JSON

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

{
    "created_epoch": "1251676800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1530662400000",
    "number": "1881827434",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 24116",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392254116",
            "telephone_number": "601-825-7280",
            "fax_number": "601-825-8130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "125 SCHOOL RD",
            "address_2": "MIZE ATTENDANCE CENTER",
            "city": "MIZE",
            "state": "MS",
            "postal_code": "39116",
            "telephone_number": "601-825-7280",
            "fax_number": "601-825-8130"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY HEALTH CARE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-31",
        "last_updated": "2018-07-04",
        "status": "A",
        "authorized_official_last_name": "CLAYTON",
        "authorized_official_first_name": "KARINA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "601-825-7280"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02829320",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE TYPE - UNSPECIFIED",
            "identifier": "251803",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mize, MS

Sources for this page

Verify at the official NPI Registry.