NPIMap

Organization Active NPI

Northeast Florida Health Services, Inc.

Doing business as Family Health Source

  • Federally Qualified Health Center (FQHC)
  • Pierson, FL
National Provider Identifier
1992792311
Registry record updated Mar 16, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST FLORIDA HEALTH SERVICES, INC.
Doing business as
Family Health Source
Practice address
216 N. Frederick Street
Pierson, FL 32180
Phone
(386) 202-6025
Fax
(386) 200-4563
NPI assigned
Sep 30, 2005
Organization subpart
Yes
Parent organization
NORTHEAST FLORIDA HEALTH SERVICES, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 16, 2023

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

Authorized official

Name
Dina Geoghegan
Title
Credentialing/Contracts Admin
Phone
(386) 327-4781

Specialties & licenses 1

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

Addresses

Primary practice location

216 N. Frederick Street
Pierson, FL 32180

Mailing address

1205 S Woodland Blvd Ste 3
Deland, FL 32720-7464
Phone (386) 202-6025

Other identifiers 1

IdentifierTypeStateIssuer
687955100MedicaidFL

Other names 1

  • Family Health Source Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL4 enrollments

Enrollment records 4

Enrollment IDStateProvider typePAC IDDetails
O20040819000233 FL Part B Supplier - Clinic/Group Practice 0547249518 Receives reassigned benefits from 25 practitioners
5 other NPIs on this enrollment
Practice locations: Deland, FL; Deltona, FL; Pierson, FL; South Daytona, FL
O20100901000543 FL Part A Provider - Federally Qualified Health Center (FQHC) 0547249518 Practice locations: Pierson, FL
O20130814000255 FL Part A Provider - Federally Qualified Health Center (FQHC) 0547249518 2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Deland, FL
O20170621002498 FL Part A Provider - Federally Qualified Health Center (FQHC) 0547249518 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: South Daytona, FL

NPI to CCN mapping 3

The Medicare certification numbers (CCNs) connected to NPI 1992792311. Details of each certification follow.

Federally qualified health center certification: CCN 101960

Legal name
NORTHEAST FLORIDA HEALTH SERVICES, INC
Doing business as
FAMILY HEALTH SOURCE MEDICAL CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 9, 2004
Last certification
Aug 9, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 22, 2002 in FL
Enrollment address
216 Frederick St
Pierson, FL 32180-3024

Federally qualified health center certification: CCN 101127

Legal name
NORTHEAST FLORIDA HEALTH SERVICES, INC
Doing business as
FAMILY HEALTH SOURCE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 14, 2013
Last certification
Aug 14, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 22, 2002 in FL
Enrollment address
1205 S Woodland Blvd, Ste 5
Deland, FL 32720-7464

Federally qualified health center certification: CCN 681097

Legal name
NORTHEAST FLORIDA HEALTH SERVICES, INC
Doing business as
FAMILY HEALTH SOURCE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 21, 2017
Last certification
Jun 21, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 1, 2004 in FL
Enrollment address
801 Beville Rd, Ste 101&102
South Daytona, FL 32119-1860

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 3

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

National Provider Directory

National Provider Directory
Part of
Northeast Florida Health

Locations

801 Beville Rd
South Daytona, FL 32119
Phone (352) 213-4295

Networks

  • Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)
  • Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Máximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Bruines Ramirez Individual Corporate OfficerCheif Operating Officer Sep 1, 2022
W-2 Managing EmployeeChief Officer of Operations Aug 1, 2022
Operational/Managerial ControlChief Officer of Operations Aug 1, 2022 100%
Vivian Campbell Individual Corporate DirectorBoard Member Jan 1, 2016
Lomax Tyus Individual Corporate DirectorBoard Member Aug 19, 2004
Catherine Cortes Individual Corporate DirectorBoard Member Apr 1, 2008
Kathryn Serpe Individual Corporate DirectorBoard Member Aug 4, 2011
Laurie Asbury Individual Corporate OfficerCeo Oct 17, 2014 100%
Corporate OfficerCeo Apr 1, 2013
W-2 Managing EmployeeCeo Apr 1, 2013
Corporate OfficerChief Executive Officer Oct 17, 2014 100%
W-2 Managing EmployeeCeo Oct 17, 2014
Nigel Hinds Individual Corporate Director Jan 25, 2010
Corporate DirectorBoard Member Jan 25, 2010
Carmen Rivera-Spelorzi Individual Corporate DirectorBoard Member Jan 1, 2016
Corporate DirectorBoard Member Oct 27, 2014

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 SourceDeltona, FL, CCN 681156 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2020

Owned or controlled facilities with NPI records 1

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

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 27

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 27

NPI Registry JSON

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

{
    "created_epoch": "1128038400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678924800000",
    "number": "1992792311",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1205 S WOODLAND BLVD STE 3",
            "city": "DELAND",
            "state": "FL",
            "postal_code": "327207464",
            "telephone_number": "386-202-6025",
            "fax_number": "386-749-9947"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "216 N. FREDERICK STREET",
            "city": "PIERSON",
            "state": "FL",
            "postal_code": "32180",
            "telephone_number": "386-202-6025",
            "fax_number": "386-200-4563"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST FLORIDA HEALTH SERVICES, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTHEAST FLORIDA HEALTH SERVICES, INC.",
        "enumeration_date": "2005-09-30",
        "last_updated": "2023-03-16",
        "certification_date": "2023-03-16",
        "status": "A",
        "authorized_official_last_name": "GEOGHEGAN",
        "authorized_official_first_name": "DINA",
        "authorized_official_title_or_position": "CREDENTIALING/CONTRACTS ADMIN",
        "authorized_official_telephone_number": "386-327-4781"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "687955100",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Health Source",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pierson, FL

Sources for this page

Verify at the official NPI Registry.