NPIMap

Organization Active NPI

Crittenden Community Hospital LLC

  • Rural Health Clinic/Center
  • Marion, KY
National Provider Identifier
1962090134
Registry record updated Jan 4, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CRITTENDEN COMMUNITY HOSPITAL LLC
Practice address
518 W Gum St
Marion, KY 42064-1516
Phone
(270) 965-5238
NPI assigned
Jan 4, 2021
Organization subpart
Yes
Parent organization
CRITTENDEN COMMUNITY HOSPITAL LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 4, 2021

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

Authorized official

Name
Darrel Morris
Title
Coo
Phone
(918) 527-1234

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

518 W Gum St
Marion, KY 42064-1516

Mailing address

518 W Gum St
Marion, KY 42064-1516
Phone (270) 965-5238

Other names 1

  • Family Practice Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210218000348 KY Part A Provider - Rural Health Clinic 8426398793 Practice locations: Marion, KY

Rural health clinic certification: CCN 188536

Legal name
CRITTENDEN COMMUNITY HOSPITAL LLC
Doing business as
FAMILY PRACTICE CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 4, 2021
Last certification
Jan 22, 2015
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Oct 9, 2018 in KY
Enrollment address
518 W Gum St
Marion, KY 42064-1516
Related CCNs
180095

All disclosed owners & managing parties 9

Medicare enrollment files

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

NameRoleSinceShare
Darrel W Morris Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 17.25%
Corporate OfficerCoo & Board Member Jan 4, 2021 17.25%
Corporate DirectorCoo & Board Member Jan 4, 2021 17.25%
Operational/Managerial ControlCoo & Board Member Jan 4, 2021 17.25%
RHG Consolidated LLC Organization, Kansas City, MO LLC, Management services company, For-profit 5% Or Greater Direct Ownership Interest Jan 4, 2021 100%
Operational/Managerial Control Jan 4, 2021 100%
Lawrence J Arthur Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 17.71%
Trent M Skaggs Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 17.71%
Corporate OfficerPresident & Board Member Jan 4, 2021 17.71%
Corporate DirectorPresident & Board Member Jan 4, 2021 17.71%
Operational/Managerial ControlPresident & Board Member Jan 4, 2021 17.71%
LG Medical LLC Organization, Kansas City, MO LLC, Medical provider/supplier, Investment firm, For-profit 5% Or Greater Indirect Ownership Interest Jan 4, 2021 11.27%
Brent Lagergren Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 6.27%
Corporate OfficerVP & Chief Compliance Officer Jan 4, 2021 6.27%
Billy W May Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 5.81%
Corporate OfficerVP & Board Member Jan 4, 2021 5.81%
Corporate DirectorVP & Board Member Jan 4, 2021 5.81%
Operational/Managerial ControlVP & Board Member Jan 4, 2021 5.81%
Dennis L Davis Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 17.71%
Paul Guastello Individual 5% Or Greater Indirect Ownership Interest Jan 4, 2021 11.27%

Change-of-ownership history 1

Medicare enrollment files
DateEventCounterparty
Jan 4, 2021 Change of OwnershipThis provider was the buyer Family Practice Clinic PSCCCN 183963, KY, NPI 1467454041

National Provider Directory

National Provider Directory
Tax ID family
Crittenden Community Hospital LLC4 organizations share this tax ID, including this one
Part of
Crittenden Community Hospital LLC

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

21234 Marion Rd
Fredonia, KY 42411
Phone (270) 545-2929

Other NPIs with the same Medicare PAC ID 4

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

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Facilities with the same owner 11

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

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1609718400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1609718400000",
    "number": "1962090134",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "518 W GUM ST",
            "city": "MARION",
            "state": "KY",
            "postal_code": "420641516",
            "telephone_number": "270-965-5238"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "518 W GUM ST",
            "city": "MARION",
            "state": "KY",
            "postal_code": "420641516",
            "telephone_number": "270-965-5238"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRITTENDEN COMMUNITY HOSPITAL LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CRITTENDEN COMMUNITY HOSPITAL LLC",
        "enumeration_date": "2021-01-04",
        "last_updated": "2021-01-04",
        "certification_date": "2021-01-04",
        "status": "A",
        "authorized_official_last_name": "MORRIS",
        "authorized_official_first_name": "DARREL",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "918-527-1234"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Practice Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marion, KY

Sources for this page

Verify at the official NPI Registry.