NPIMap

Organization Active NPI

Family Health Center of Southern Oklahoma Inc

  • Federally Qualified Health Center (FQHC)
  • Kingston, OK
National Provider Identifier
1982267910
Registry record updated Aug 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC
Practice address
21 N Main St
Kingston, OK 73439-6562
Phone
(580) 564-7885
Fax
(580) 564-7902
NPI assigned
Apr 16, 2019
Last updated
Aug 21, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 21, 2024

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

Authorized official

Name
Ashley Wells
Title
Credentialing Officer
Phone
(580) 387-0509

Specialties & licenses 1

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

Addresses

Primary practice location

21 N Main St
Kingston, OK 73439-6562

Mailing address

610 E 24TH St
Tishomingo, OK 73460-3245
Phone (580) 371-2343

Other identifiers 1

IdentifierTypeStateIssuer
200018910GMedicaidOK

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040127001108 OK Part B Supplier - Clinic/Group Practice 4284537457 Receives reassigned benefits from 32 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Kingston, OK; Tishomingo, OK; Milburn, OK; Coalgate, OK; Atoka, OK
O20191101000097 OK Part A Provider - Federally Qualified Health Center (FQHC) 4284537457 Practice locations: Kingston, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1982267910. Details of each certification follow.

Federally qualified health center certification: CCN 371949

Legal name
FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 5, 2019
Last certification
Nov 5, 2019
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 15, 2002 in OK
Enrollment address
21 N Main St
Kingston, OK 73439-6562

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 4

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
37D2169578Family Health Center of Southern Ok21 N Main, Kingston, OK 73439Certificate of waiverJul 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
Family Health Center of Southern Oklahoma Inc5 organizations share this tax ID, including this one
Part of
Family Health Center of Southern Oklahoma Inc

Other organizations with this tax ID 4

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Daniel Ibarra Individual Corporate DirectorBoard Member Jan 1, 2019
Janie Cagle Individual Corporate DirectorBoard Member Jan 1, 2007
Wanda Y Kelly Individual Corporate DirectorBoard Member Jan 1, 2015
Seigel Heffington Individual Corporate DirectorBoard Member Jan 1, 2004
Family Health Center of Southern Oklahoma Inc Organization, Tishomingo, OK Non-profit Operational/Managerial Control Aug 13, 2019
Tommy R Winkler Individual Corporate DirectorBoard Member Jan 1, 2014
Richard Sowder Individual Corporate DirectorBoard Member Sep 1, 2005
Tina Davis Individual Corporate DirectorCeo Aug 13, 2019
Operational/Managerial ControlCeo Aug 13, 2019
Gary L McDonald Individual Corporate DirectorBoard Member Jun 18, 2015
Jennifer Bartel Individual Corporate DirectorBoard Member Jul 1, 2019
Fran Morrell Individual Corporate DirectorBoard Member Jan 1, 2004
Steve Cheadle Individual Corporate DirectorBoard Member Jul 1, 2019

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Family Health Center of Southern Oklahoma IncCoalgate, OK, CCN 371864 Federally qualified health center Operational/Managerial Control Nov 1, 2010

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 12

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": "1555372800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724198400000",
    "number": "1982267910",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "610 E 24TH ST",
            "city": "TISHOMINGO",
            "state": "OK",
            "postal_code": "734603245",
            "telephone_number": "580-371-2343",
            "fax_number": "580-371-3614"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21 N MAIN ST",
            "city": "KINGSTON",
            "state": "OK",
            "postal_code": "734396562",
            "telephone_number": "580-564-7885",
            "fax_number": "580-564-7902"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA INC",
        "enumeration_date": "2019-04-16",
        "last_updated": "2024-08-21",
        "certification_date": "2024-08-21",
        "status": "A",
        "authorized_official_last_name": "WELLS",
        "authorized_official_first_name": "ASHLEY",
        "authorized_official_title_or_position": "CREDENTIALING OFFICER",
        "authorized_official_telephone_number": "580-387-0509"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200018910G",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kingston, OK

Sources for this page

Verify at the official NPI Registry.