NPIMap

Organization Active NPI

Shoalwater Bay Tribe

Doing business as Shoalwater Bay Tribal Clinic

  • Primary Care Clinic/Center
  • Tokeland, WA
National Provider Identifier
1063624740
Registry record updated Aug 25, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
SHOALWATER BAY TRIBE
Doing business as
Shoalwater Bay Tribal Clinic
Practice address
2373 Old Tokeland Rd
Tokeland, WA 98590
Phone
(360) 267-0119
Fax
(360) 267-0417
NPI assigned
May 4, 2007
Last updated
Aug 25, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 25, 2015

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

Authorized official

Name
Mr. Michael Rogers
Title
Tribal Administrator
Phone
(360) 267-6766

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU Primary

Addresses

Primary practice location

2373 Old Tokeland Rd
Tokeland, WA 98590

Mailing address

PO Box 500
Tokeland, WA 98590-0500
Phone (360) 267-0119

Other names 1

  • Shoalwater Bay Tribal Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040305000564 WA Part B Supplier - Clinic/Group Practice 8820986599 Receives reassigned benefits from 5 practitioners
Practice locations: Tokeland, WA
O20050201000875 WA Part A Provider - Federally Qualified Health Center (FQHC) 8820986599 Practice locations: Tokeland, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063624740. Details of each certification follow.

Federally qualified health center certification: CCN 501890

Legal name
SHOALWATER BAY TRIBE
Doing business as
SHOALWATER BAY TRIBAL CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 30, 2005
Last certification
Aug 30, 2005
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
2373 Old Tokeland Road
Building E
Tokeland, WA 98590-9729

National Provider Directory

National Provider Directory
Tax ID family
Shoalwater Bay Tribe7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

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
Shane Thomas Individual Corporate OfficerMember-at-Large, Shoalwater Bay Mar 1, 2021
Kimberly a Coombs Individual Corporate DirectorHealth Director Jul 9, 2012
W-2 Managing EmployeeHealth Director Apr 6, 2012
Larry R Kerns Individual Corporate DirectorChief Financial Officer, Interim Aug 1, 2009
W-2 Managing EmployeeTribal Administrator Aug 1, 2009
Operational/Managerial ControlTribal Administrator Dec 15, 2021
Lynn Clark Individual Corporate OfficerSecretary, Shoalwater Bay Tribal Mar 20, 2015
Charlene R Nelson Individual Corporate OfficerChairwoman, Shoalwater Bay Triba Mar 20, 2016
Linda L Kauzlarich Individual W-2 Managing EmployeeContract Health Services & Provi Jan 1, 2015
Joel a Blake Individual Corporate OfficerVice-Chairman, Shoalwater Bay TR Mar 20, 2021
Quintin Swanson Individual Corporate OfficerTreasurer, Shoalwater Bay Tribal Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1178236800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1440460800000",
    "number": "1063624740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 500",
            "city": "TOKELAND",
            "state": "WA",
            "postal_code": "985900500",
            "telephone_number": "360-267-0119",
            "fax_number": "360-267-0417"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2373 OLD TOKELAND RD",
            "city": "TOKELAND",
            "state": "WA",
            "postal_code": "98590",
            "telephone_number": "360-267-0119",
            "fax_number": "360-267-0417"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOALWATER BAY TRIBE",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-04",
        "last_updated": "2015-08-25",
        "status": "A",
        "authorized_official_last_name": "ROGERS",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "TRIBAL ADMINISTRATOR",
        "authorized_official_telephone_number": "360-267-6766",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shoalwater Bay Tribal Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tokeland, WA

Sources for this page

Verify at the official NPI Registry.