NPIMap

Organization Active NPI

Ponderosa Family Care, LLC

  • Rural Health Clinic/Center
  • Payson, AZ
National Provider Identifier
1992321723
Registry record updated Jun 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PONDEROSA FAMILY CARE, LLC
Practice address
127 E Main St Ste D
Payson, AZ 85541-5646
Phone
(928) 468-8603
Fax
(928) 468-8625
NPI assigned
Jun 17, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2020

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

Authorized official

Name
Dr. Alan P Michels, MDNPI 1376512129
Title
Physician/Owner
Phone
(928) 468-8603

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

127 E Main St Ste D
Payson, AZ 85541-5646

Mailing address

PO Box 2901
Payson, AZ 85547-2901
Phone (928) 468-8603

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20101208000388 AZ Part B Supplier - Clinic/Group Practice 1456548015 Receives reassigned benefits from 14 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Payson, AZ
O20200820002361 AZ Part A Provider - Rural Health Clinic 1456548015 Practice locations: Payson, AZ

Rural health clinic certification: CCN 033844

Legal name
PONDEROSA FAMILY CARE LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 7, 2021
Last certification
Jan 7, 2021
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Aug 23, 2020 in AZ
Enrollment address
127 E Main St
Ste D
Payson, AZ 85541-5646

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

708 S Coeur D Alene Ln
Payson, AZ 85541
Phone (602) 239-6324

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Diane a Vohs Individual W-2 Managing EmployeePractice Administrator Sep 1, 2010
Alan P Michels Individual 5% Or Greater Direct Ownership Interest Aug 23, 2010
W-2 Managing Employee Aug 23, 2010

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 13

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

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1592352000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1592352000000",
    "number": "1992321723",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2901",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855472901",
            "telephone_number": "928-468-8603",
            "fax_number": "928-468-8625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "127 E MAIN ST STE D",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855415646",
            "telephone_number": "928-468-8603",
            "fax_number": "928-468-8625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PONDEROSA FAMILY CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-06-17",
        "last_updated": "2020-06-17",
        "certification_date": "2020-06-17",
        "status": "A",
        "authorized_official_last_name": "MICHELS",
        "authorized_official_first_name": "ALAN",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PHYSICIAN/OWNER",
        "authorized_official_telephone_number": "928-468-8603",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Payson, AZ

Sources for this page

Verify at the official NPI Registry.