Bandon Community Health Ctr
Organization Active NPI Federally Qualified Health Center (FQHC) · Port Orford, OR
NPI 1013587484 · NPPES record last updated Jun 29, 2021
Key facts
- NPI
- 1013587484
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- BANDON COMMUNITY HEALTH CTR
- Practice address
- 312 Tichenor St
Port Orford, OR 97465-8672 - Phone
- (541) 347-2529
- Fax
- (541) 347-9196
- NPI assigned
- Jun 29, 2021
- Organization subpart
- Yes
- Parent organization (as reported)
- BANDON COMMUNITY HEALTH CTR
Authorized official
- Name
- Linda S Maxon
- Title
- Ceo
- Phone
- (541) 347-2529
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 1
Practitioners 22
-
Christina Marie Brakebill, RN, FNP-BC
-
Kimberly Jean Gray, MS, LPC, CM
-
Lindsay Rose Iannone, PA-C, MSPAS
-
Elizabeth Anne Neeley, M.D.
-
Diane Michele Reid, ARNP
-
Amanda Blakely, DNP
-
Stephanie Ann Empson, FNP
-
Celyn Ijeoma Hughes, FNP-BC, RN
-
Jenny Lascheck, LPC
-
Harold D Lowry, MD
-
Shilo Marie McKenzie, CNMNP
-
Tracy Ann Merriam, LCSW
-
Karen Jane Olson, CFNP-APRN
-
Rachel Anne Rainey, LCSW
-
Rebecca Marie Rice, LCSW
-
Michael Anthony Torres, MD, MBA
-
Paul C Vitt, DO
-
Ivy Christine Wagner, DBH, LCSW
-
Kim Bagby, APRN
-
Debra Lee Doornbos, FNP-BC, MSN
-
Cynthia Diane Gray, LCSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in OR
Federally qualified health center certification: CCN 381009
- Legal name
- BANDON COMMUNITY HEALTH CENTER
- Certification status
- Terminated Voluntary: merger or closure, Sep 30, 2025
- Provider type (POS)
- Federally qualified health center
- Participating since
- Aug 3, 2022
- Last certification
- Aug 3, 2022
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 13, 2009 in OR
- Enrollment address
- 1312 Tichenor St
Port Orford, OR 97465-8776
All disclosed owners & managing parties 9
| Name | Role | Since | Share |
|---|---|---|---|
| Mari Lochhaas |
Corporate Director |
Jan 13, 2022 | |
| Bryan Thompson |
Corporate Director |
Feb 4, 2022 | |
| Greg Fodrea |
Corporate Director |
Jun 25, 2021 | |
| Joseph McLeod |
Corporate Director |
Jul 26, 2017 | |
| Linda S Maxon |
Corporate Officer |
Jan 3, 2010 | 100% |
| W-2 Managing Employee |
Jan 3, 2010 | 100% | |
| David Gerhart |
Corporate Director |
Mar 1, 2019 | |
| Steven Borror |
Corporate Director |
Mar 1, 2019 | |
| Nicole C Heitzman |
W-2 Managing Employee |
Dec 31, 2020 | 100% |
| Operational/Managerial Control |
Dec 31, 2020 | 100% | |
| Anne Goddard |
Corporate Director |
Feb 15, 2022 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100430000431 | OR | Part B Supplier - Clinic/Group Practice | 1557416757 |
Receives reassigned benefits from 22 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Bandon, OR; Port Orford, OR |
| O20220805002034 | OR | Part a Provider - Federally Qualified Health Center (FQHC) | 1557416757 | Practice locations: Port Orford, OR |
National Provider Directory
- Part of
- Bandon Community Health Center
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
312 Tichenor St
Port Orford, OR 97465-8672
Mailing address
1010 1St St SE Ste 110
Bandon, OR 97411-9301
Phone (541) 347-2529
Other names
- Coast Community Health Center
Other providers in Port Orford, OR
- Adapt
- Adapt
- Bandon Community Health Ctr
- Curry Health District
- Malori Page Dixon
- Janine Jason
- Sandra P. Johnson
All providers in Port Orford, OR · Federally Qualified Health Center (FQHC) in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 29, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.