NPIMap

Organization Active NPI

Benton Medical

  • Clinic/Center
  • Benton, LA
National Provider Identifier
1932585841
Registry record updated Jan 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
BENTON MEDICAL
Practice address
188 Burt Blvd
Benton, LA 71006-4900
Phone
(318) 965-5017
Fax
(318) 965-5019
NPI assigned
Aug 3, 2015
Last updated
Jan 29, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTH CADDO HOSPITAL SERVICE DISTRICTAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 29, 2024

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

Authorized official

Name
Dakota James Robinson
Title
Cfo
Phone
(318) 375-4097

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU Primary

Addresses

Primary practice location

188 Burt Blvd
Benton, LA 71006-4900

Mailing address

188 Burt Blvd
Benton, LA 71006-4900
Phone (318) 375-4004

Other identifiers 1

IdentifierTypeStateIssuer
2508784MedicaidLA

Electronic endpoints 2

TypeEndpointUseAffiliation
Direct Messaging Address jerethompson@ncmc.allscriptsdirect.net Direct
Direct Messaging Address nicolemccommon@ncmc.allscriptsdirect.net Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20151008001618 LA Part B Supplier - Clinic/Group Practice 1456669654 Receives reassigned benefits from 16 practitioners
Practice locations: Benton, LA
O20191121001848 LA Part A Provider - Rural Health Clinic 1456669654 Practice locations: Benton, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1932585841. Details of each certification follow.

Rural health clinic certification: CCN 198513

Legal name
BENTON MEDICAL
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 24, 2019
Last certification
Nov 6, 2019
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
188 Burt Blvd
Benton, LA 71006-4900
Related CCNs
191304

Facilities connected through Provider of Services related, parent or unit certification numbers.

National Provider Directory

National Provider Directory
Part of
Charles L Metzger MD

Interoperability endpoints

  • Direct secure messaging: jerethompson@ncmc.allscriptsdirect.net

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
Dakota Robinson Individual Operational/Managerial ControlCfo Oct 28, 2018
Thomas Tebbe Individual Corporate Officer Feb 1, 2024
Robert Green Individual Operational/Managerial ControlBoard of Directors Member Nov 3, 2017 100%
North Caddo Hospital Service District Organization, Vivian, LA Operational/Managerial Control Nov 3, 2015 100%
Michael Nation Individual Corporate Officer Aug 5, 2021
Jennifer Fant Individual Corporate Officer Jun 7, 2022
David Jones Individual Corporate DirectorCeo Aug 1, 2017
Operational/Managerial ControlBoard of Directors Nov 3, 2015 100%
Brenda Smith Individual Operational/Managerial ControlBoard of Directors Member Nov 3, 2015 100%
Kenneth Cochran Individual Corporate Officer Jul 19, 2018
David Norman Individual Operational/Managerial ControlBoard of Directors Member Nov 3, 2015 100%
Mary Irvin Individual Operational/Managerial ControlBoard of Directors Member Nov 3, 2015 100%

Owners & managing parties with NPI records 3

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

Facilities with the same owner 4

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

Practitioners & affiliated clinicians

Practitioners 17

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 17

NPI Registry JSON

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

{
    "created_epoch": "1438560000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706486400000",
    "number": "1932585841",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "188 BURT BLVD",
            "city": "BENTON",
            "state": "LA",
            "postal_code": "710064900",
            "telephone_number": "318-375-4004"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "188 BURT BLVD",
            "city": "BENTON",
            "state": "LA",
            "postal_code": "710064900",
            "telephone_number": "318-965-5017",
            "fax_number": "318-965-5019"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BENTON MEDICAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTH CADDO HOSPITAL SERVICE DISTRICT",
        "enumeration_date": "2015-08-03",
        "last_updated": "2024-01-29",
        "certification_date": "2024-01-29",
        "status": "A",
        "authorized_official_last_name": "ROBINSON",
        "authorized_official_first_name": "DAKOTA",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "318-375-4097"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2508784",
            "state": "LA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jerethompson@ncmc.allscriptsdirect.net",
            "affiliation": "N",
            "endpointDescription": "Benton Medical - jerethompson@ncmc.allscriptsdirect.net",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCDA",
            "address_1": "188 Burt Blvd",
            "city": "Benton",
            "state": "LA",
            "country_code": "US",
            "postal_code": "710064900",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "nicolemccommon@ncmc.allscriptsdirect.net",
            "affiliation": "N",
            "endpointDescription": "Benton Medical - nicolemccommon@ncmc.allscriptsdirect.net",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCDA",
            "address_1": "188 Burt Blvd",
            "city": "Benton",
            "state": "LA",
            "country_code": "US",
            "postal_code": "710064900",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Benton, LA

Sources for this page

Verify at the official NPI Registry.