NPIMap

Organization Active NPI

Ocoee Regional Health Corporation

Doing business as Grundy County Primary Care Center

  • Federally Qualified Health Center (FQHC)
  • Coalmont, TN
National Provider Identifier
1902010770
Registry record updated Jun 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
OCOEE REGIONAL HEALTH CORPORATION
Doing business as
Grundy County Primary Care Center
Practice address
10120 Sr 56
Coalmont, TN 37313-2505
Phone
(931) 779-4002
Fax
(931) 779-4003
NPI assigned
May 10, 2007
Last updated
Jun 29, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2021

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

Authorized official

Name
Mr. Bill R Moats
Title
Ceo
Phone
(423) 338-8995

Specialties & licenses 1

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

Addresses

Primary practice location

10120 Sr 56
Coalmont, TN 37313-2505

Mailing address

PO Box 70
Palmer, TN 37365-0070
Phone (931) 779-4002

Other names 1

  • Grundy County Primary Care Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040412001630 TN Part B Supplier - Clinic/Group Practice 1355233693 Receives reassigned benefits from 32 practitioners
1 other NPI on this enrollment
Practice locations: Decatur, TN; Pikeville, TN; Dayton, TN; Coalmont, TN; Cleveland, TN; Benton, TN
O20100820001096 TN Part A Provider - Federally Qualified Health Center (FQHC) 1355233693 Practice locations: Coalmont, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902010770. Details of each certification follow.

Federally qualified health center certification: CCN 441867

Legal name
OCOEE REGIONAL HEALTH CORPORATION
Doing business as
GRUNDY COUNTY PRIMARY CARE CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 25, 1994
Last certification
Jul 25, 1994
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 22, 1978 in TN
Enrollment address
10120 Sr 56
Coalmont, TN 37313-2505

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 1

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
44D0904148Grundy County Primary Care Center10120 Sr 56, Coalmont, TN 37313ComplianceJan 6, 2028

National Provider Directory

National Provider Directory

Locations

1420 Fritz St SE
Cleveland, TN 37323
Phone (423) 380-6383

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Kimberly Bishop Individual Corporate Director Aug 12, 2010
Ocoee Regional Health Corporation Organization, Benton, TN Corporation, Non-profit Operational/Managerial Control Jan 1, 1990
William Moats Individual Corporate DirectorCeo Aug 12, 2010
W-2 Managing EmployeeCeo Aug 12, 2010
Skylar Creasman Individual Corporate OfficerBoard Member May 1, 2021
Charles Ross Individual Corporate OfficerBoard Member Jun 1, 2022
Patti Dalton Individual Corporate Director Nov 3, 2010
Pearson Devaul Individual W-2 Managing EmployeeCoo Jan 1, 2018
Linda Davis Individual Corporate Director Aug 12, 2010
Bill Hollin Individual Corporate Director Aug 12, 2010
Chandler Blakely Individual Corporate OfficerCfo Mar 1, 2021
W-2 Managing EmployeeChief Financial Officer Mar 1, 2021
Rita Hammons Individual Corporate Director Aug 12, 2010
John Myers Individual Corporate Director May 1, 2014
Nelson Cope Individual Corporate DirectorBoard of Director Jan 1, 2020

Owners & managing parties with NPI records 11

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Benton Family Health Care CenterBenton, TN, CCN 441817 Federally qualified health center Operational/Managerial Control Jul 1, 1978

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 32

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.

View all 32

NPI Registry JSON

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

{
    "created_epoch": "1178755200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1624924800000",
    "number": "1902010770",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 70",
            "city": "PALMER",
            "state": "TN",
            "postal_code": "373650070",
            "telephone_number": "931-779-4002",
            "fax_number": "931-779-4003"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10120 SR 56",
            "city": "COALMONT",
            "state": "TN",
            "postal_code": "373132505",
            "telephone_number": "931-779-4002",
            "fax_number": "931-779-4003"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OCOEE REGIONAL HEALTH CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-10",
        "last_updated": "2021-06-29",
        "certification_date": "2021-06-29",
        "status": "A",
        "authorized_official_last_name": "MOATS",
        "authorized_official_first_name": "BILL",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "423-338-8995",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Grundy County Primary Care Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Grundy County Primary Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Coalmont, TN

Sources for this page

Verify at the official NPI Registry.