Fast Pace Mississippi, PLLC
Organization Active NPI Rural Health Clinic/Center · Hazlehurst, MS
NPI 1912664293 · NPPES record last updated Nov 22, 2021
Key facts
- NPI
- 1912664293
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- FAST PACE MISSISSIPPI, PLLC
- Practice address
- 533 Lake St
Hazlehurst, MS 39083-2217 - Phone
- (601) 552-5253
- NPI assigned
- Nov 22, 2021
- Organization subpart
- No
Authorized official
- Name
- Sydni Clemmons
- Title
- Credentialing Manager
- Phone
- (901) 351-1791
Owners & managing parties with NPI records 1
-
Dana Kay Martin, C.F.N.P.
Other NPIs on the same Medicare enrollment 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Rural health clinic certification: CCN A53811
- Legal name
- FAST PACE MISSISSIPPI PLLC
- Doing business as
- FAST PACE HEALTH
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 27, 2022
- Last certification
- Jan 27, 2022
- Ownership / control type
- 1B
- Organization structure
- Other · Proprietary
- Incorporated
- Sep 15, 2017 in MS
- Enrollment address
- 533 Lake St
Hazlehurst, MS 39083-2217
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Sydni Clemmons |
Corporate Director |
Dec 1, 2021 | |
| W-2 Managing Employee |
Dec 1, 2021 | ||
| Dana Kay Martin |
5% Or Greater Direct Ownership Interest | Dec 1, 2021 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20211208000891 | MS | Part a Provider - Rural Health Clinic | 3678832029 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Hazlehurst, MS |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
533 Lake St
Hazlehurst, MS 39083-2217
Mailing address
PO Box 306415
Nashville, TN 37230-6415
Other providers in Hazlehurst, MS
- Troy Donald Douglas
- Jason Downard
- Clay Eckerson
- George E Ellis
- Family Wellness & Chiropractic
- Freds Stores of Tennessee Inc
- G & T Pharmaceutical Inc
- Gamblin Orthodontics PLLC
- Jefferson Ridgway Gamblin
- Garcia Group LLC
All providers in Hazlehurst, MS · Rural Health Clinic/Center in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 22, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.