NPIMap

Organization Active NPI

Community Health Center of Snohomish County

  • Federally Qualified Health Center (FQHC)
  • Lynnwood, WA
National Provider Identifier
1013049741
Registry record updated Sep 22, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
7034036 Issued in WA
Legal business name
COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Practice address
4111 194TH St SW Ste 100
Lynnwood, WA 98036-4604
Phone
(425) 835-5200
Fax
(425) 835-5201
NPI assigned
Mar 9, 2007
Last updated
Sep 22, 2010By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 22, 2010

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

Authorized official

Name
Mr. Kenneth M Green
Title
Executive Director
Phone
(425) 789-3700

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 7034036 WA
Federally Qualified Health Center (FQHC) 261QF0400X 7034036 WA Primary

Addresses

Primary practice location

4111 194TH St SW Ste 100
Lynnwood, WA 98036-4604

Mailing address

PO Box 13060
Everett, WA 98206-3060
Phone (425) 789-3700

Other identifiers 3

IdentifierTypeStateIssuer
7034036MedicaidWA
32770OtherWAWORKMAN COMPENSATION
8934243OtherWACRIME VICTIM COMPENSATION

Other names 1

  • Community Health Center of Snohomish County Lynnwood Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101101000968 WA Part A Provider - Federally Qualified Health Center (FQHC) 0446152003 Practice locations: Lynnwood, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013049741. Details of each certification follow.

Federally qualified health center certification: CCN 501850

Legal name
COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 1, 1995
Last certification
Jan 1, 1995
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Mar 21, 1984 in WA
Enrollment address
4111 194TH SWST
Lynnwood, WA 98036-4604

Other NPIs with the same Medicare PAC ID 17

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

View all 17

National Provider Directory

National Provider Directory
Tax ID family
Comm HLTH Ctr Snohomis Cty29 organizations share this tax ID, including this one
Part of
Comm HLTH Ctr Snohomis Cty

Other organizations with this tax ID 28

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

View all 28

Locations

4111 194th St SW
Ste 100
Lynnwood, WA 98036
Phone (425) 835-5200

4111 194th St SW
Ste 101
Lynnwood, WA 98036
Phone (425) 835-5200

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
Julian King Individual Corporate OfficerBoard Member Jan 1, 2020
Dion C Kapetanov Individual W-2 Managing EmployeeCao Dec 1, 2010
Joseph E Vessey Individual Corporate OfficerCeo Dec 1, 2019
W-2 Managing EmployeeCeo Dec 1, 2019
Robert Maxwell Individual Corporate OfficerBoard Member Jan 1, 2020
Sue M Yoon Individual Corporate OfficerChief Dental Officer Aug 2, 2010
Sandra Toussaint Individual Corporate OfficerBoard Member Jan 1, 2020
Tove Doyle-Skaftun Individual Corporate OfficerChief Nursing Officer Jan 26, 2004
Charles Mister Individual Corporate OfficerBoard Member Jan 1, 2020
Edward Rogan Individual Corporate OfficerChair Dec 1, 2016
Olivia D Mathisen-Holloman Individual Corporate OfficerChair Feb 1, 2017
Joel a Emery Individual Corporate OfficerCfo Feb 5, 2024
W-2 Managing EmployeeCfo Feb 5, 2024
Jessica Enick Individual Corporate OfficerBoard Member Jan 1, 2020

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 2

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": "1173398400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1285113600000",
    "number": "1013049741",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 13060",
            "city": "EVERETT",
            "state": "WA",
            "postal_code": "982063060",
            "telephone_number": "425-789-3700",
            "fax_number": "425-789-3750"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4111 194TH ST SW STE 100",
            "city": "LYNNWOOD",
            "state": "WA",
            "postal_code": "980364604",
            "telephone_number": "425-835-5200",
            "fax_number": "425-835-5201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY",
        "enumeration_date": "2007-03-09",
        "last_updated": "2010-09-22",
        "status": "A",
        "authorized_official_last_name": "GREEN",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "425-789-3700",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "7034036",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WA",
            "license": "7034036",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7034036",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WORKMAN COMPENSATION",
            "identifier": "32770",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CRIME VICTIM COMPENSATION",
            "identifier": "8934243",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Health Center of Snohomish County Lynnwood",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Lynnwood, WA

Sources for this page

Verify at the official NPI Registry.