NPIMap

Organization Active NPI

Douglas County Public Health Services Group, Inc.

Doing business as Missouri Ozarks Community Health

  • Federally Qualified Health Center (FQHC)
  • Ava, MO
National Provider Identifier
1912904145
Registry record updated Jan 9, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Doing business as
Missouri Ozarks Community Health
Practice address
504 NW 10TH Avenue
Ava, MO 65608-1359
Phone
(417) 683-4831
Fax
(417) 683-1602
NPI assigned
Jul 1, 2005
Last updated
Jan 9, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 9, 2008

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

Authorized official

Name
Mr. Richard R Sims
Title
Ceo
Phone
(417) 683-4831

Specialties & licenses 1

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

Addresses

Primary practice location

504 NW 10TH Avenue
Ava, MO 65608-1359

Mailing address

PO Box 1359
504 NW 10TH Ave
Ava, MO 65608-1359
Phone (417) 683-4831

Other names 1

  • Missouri Ozarks Community Health Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20030630000021 MO Part A Provider - Federally Qualified Health Center (FQHC) 3072423052 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gainesville, MO
O20030630000024 MO Part A Provider - Federally Qualified Health Center (FQHC) 3072423052 Practice locations: Ava, MO
O20050301000128 MO Part B Supplier - Clinic/Group Practice 3072423052 Receives reassigned benefits from 33 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ava, MO; Theodosia, MO; Mountain Grove, MO; Mansfield, MO; Licking, MO; Houston, MO; Gainesville, MO; Cabool, MO

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1912904145. Details of each certification follow.

Federally qualified health center certification: CCN 261860

Legal name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Doing business as
MISSOURI OZARKS COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 1, 2001
Last certification
May 1, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1996 in MO
Enrollment address
87 Elm St
Gainesville, MO 65655-7131

Federally qualified health center certification: CCN 261859

Legal name
DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Doing business as
MISSOURI OZARKS COMMUNITY HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 1, 2001
Last certification
May 1, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 9, 1996 in MO
Enrollment address
504 W. Broadway Ave.
Ava, MO 65608

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 9

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
26D0925211Missouri Ozarks Community Health504 W Broadway Ave, Ava, MO 65608Certificate of waiverFeb 19, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Bart Ellison Individual Corporate OfficerTreasurer Sep 17, 2014 10%
Aaron Dalton Individual Corporate OfficerBoard Member Apr 21, 2021 10%
Ronald Scheets Individual Corporate OfficerBoard Member Jun 12, 2013 8%
Corporate OfficerBoard Member Jun 12, 2013 10%
Rhonda Suter Individual Corporate OfficerBoard Chair Apr 9, 2001 10%
Carol Cunningham Individual Corporate OfficerMember Jun 16, 2021 10%
Corporate OfficerMember Feb 19, 1998 10%
Tim Shryack Individual Corporate DirectorCeo Jun 17, 2013 100%
Sheldon Shaver Individual Corporate OfficerBoard Member May 25, 2016 10%
Donald Pinckney Individual Corporate OfficerBoard Vice Chair Jan 30, 1997 8%
Corporate OfficerBoard Vice Chair Jan 30, 1997 10%
Ann Leonard Individual Corporate OfficerBoard Member Jul 15, 2020 10%
Jennifer D Heinlein Individual W-2 Managing EmployeeExec. Assistant/Hro Jan 1, 2014 25%
Operational/Managerial ControlHro Jan 1, 2014 50%
W-2 Managing EmployeeExec Assistant/Hro Jan 1, 2014 25%
Valerie Reece Individual Corporate OfficerBoard Secretary Aug 8, 2012 8%
Corporate OfficerBoard Secretary Aug 8, 2012 10%

Practitioners & affiliated clinicians

Practitioners 7

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": "1120176000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1199836800000",
    "number": "1912904145",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1359",
            "address_2": "504 NW 10TH AVE",
            "city": "AVA",
            "state": "MO",
            "postal_code": "656081359",
            "telephone_number": "417-683-4831",
            "fax_number": "417-683-1602"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "504 NW 10TH AVENUE",
            "city": "AVA",
            "state": "MO",
            "postal_code": "656081359",
            "telephone_number": "417-683-4831",
            "fax_number": "417-683-1602"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-01",
        "last_updated": "2008-01-09",
        "status": "A",
        "authorized_official_last_name": "SIMS",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "417-683-4831",
        "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": "Missouri Ozarks Community Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ava, MO

Sources for this page

Verify at the official NPI Registry.