Douglas County Public Health Services Group, Inc.
Organization Active NPI Federally Qualified Health Center (FQHC) · Ava, MO
NPI 1912904145 · NPPES record last updated Jan 9, 2008
Key facts
- NPI
- 1912904145
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
- Practice address
- 504 NW 10TH Avenue
Ava, MO 65608-1359 - Phone
- (417) 683-4831
- Fax
- (417) 683-1602
- NPI assigned
- Jul 1, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Richard R Sims
- Title
- Ceo
- Phone
- (417) 683-4831
Other NPIs on the same Medicare enrollment 9
Other NPIs with the same Medicare PAC ID 6
Practitioners 26
-
Ida N Junge, FNP
-
McKenna Glyn Madche, FNP
-
Teresa Lynn Sherard, M.D.
-
Angela Sutton, LPC
-
Brenda Taylor, NP
-
Michelle Lynn Marcak, APRN
-
Shari Ranee Cook, FNP
-
Kathy L Domiano, FNP
-
Robert Christian Doneski, PSYD
-
Taylour Paige Emery, NURSE PRACTITIONER
-
David Evans, LADAC, ICAADC, ACADC
-
Mina K Higgins, FNP
-
Kody Johnson, FNP
-
Hannah Paul, LMSW
-
Kelley Renee Reed, L.C.S.W.
-
Lacy Shields, LMSW
-
Kaysha Michaele Smith, APRN, FNP-C
-
Ashlynn Vonderheide, FNP-C
-
Joshua P Wolfe, MD
-
Renee Claire Sons, FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 26D0925211 | Missouri Ozarks Community Health | Certificate of waiver | Feb 19, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in MO
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
- Corporation · Non-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
- Corporation · Non-profit
- Incorporated
- Apr 9, 1996 in MO
- Enrollment address
- 504 W. Broadway Ave.
Ava, MO 65608
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Bart Ellison |
Corporate Officer |
Sep 17, 2014 | 10% |
| Aaron Dalton |
Corporate Officer |
Apr 21, 2021 | 10% |
| Ronald Scheets |
Corporate Officer |
Jun 12, 2013 | 8% |
| Corporate Officer |
Jun 12, 2013 | 10% | |
| Rhonda Suter |
Corporate Officer |
Apr 9, 2001 | 10% |
| Carol Cunningham |
Corporate Officer |
Jun 16, 2021 | 10% |
| Corporate Officer |
Feb 19, 1998 | 10% | |
| Tim Shryack |
Corporate Director |
Jun 17, 2013 | 100% |
| Sheldon Shaver |
Corporate Officer |
May 25, 2016 | 10% |
| Donald Pinckney |
Corporate Officer |
Jan 30, 1997 | 8% |
| Corporate Officer |
Jan 30, 1997 | 10% | |
| Ann Leonard |
Corporate Officer |
Jul 15, 2020 | 10% |
| Jennifer D Heinlein |
W-2 Managing Employee |
Jan 1, 2014 | 25% |
| Operational/Managerial Control |
Jan 1, 2014 | 50% | |
| W-2 Managing Employee |
Jan 1, 2014 | 25% | |
| Valerie Reece |
Corporate Officer |
Aug 8, 2012 | 8% |
| Corporate Officer |
Aug 8, 2012 | 10% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
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
- Missouri Ozarks Community Health
Other providers in Ava, MO
- Kathy L Domiano
- Douglas County Health Department
- Douglas County Public Health Services Group, Inc.
- Douglas County Public Health Services Group, Inc.
- Douglas County Public Health Services Group, Inc.
- Douglas County Public Health Services Group, Inc.
- Douglas County Public Health Services Group, Inc.
- DRS Bowling Griffith & Antle Optometrists PC
- Jacqueline Victoria Dugan
- Connie Louise Dunn
All providers in Ava, MO · Federally Qualified Health Center (FQHC) in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 9, 2008. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.