NPIMap

Organization Active NPI

St. Joseph Health Northern California, LLC

Doing business as Providence Family Practice

  • Rural Health Clinic/Center
  • Fortuna, CA
National Provider Identifier
1194189654
Registry record updated May 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Doing business as
Providence Family Practice
Practice address
3302 Renner Dr
Fortuna, CA 95540
Phone
(707) 725-3318
NPI assigned
Apr 11, 2016
Last updated
May 7, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
ST. JOSEPH HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 7, 2025

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

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 1

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

Addresses

Primary practice location

3302 Renner Dr
Fortuna, CA 95540

Mailing address

PO Box 31001-3059
Pasadena, CA 91110-3059
Phone (707) 269-4263

Other identifiers 1

IdentifierTypeStateIssuer
1194189654MedicaidCA

Other names 1

  • PROVIDENCE FAMILY PRACTICE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180322002714 CA Part A Provider - Rural Health Clinic 8921374562 Practice locations: Fortuna, CA
O20200706001160 CA Part B Supplier - Clinic/Group Practice 8921374562 Receives reassigned benefits from 33 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Santa Rosa, CA; Fortuna, CA; Napa, CA; Eureka, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194189654. Details of each certification follow.

Rural health clinic certification: CCN 058698

Legal name
ST JOSEPH HEALTH NORTHERN CALIFORNIA LLC
Doing business as
PROVIDENCE FAMILY PRACTICE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 7, 2016
Last certification
May 27, 2014
Ownership / control type
2B
Most recent change of ownership
Apr 1, 2018 (1 total)
Organization structure
LLCNon-profit
Incorporated
Oct 27, 2016 in CA
Enrollment address
3302 Renner Dr
Ste a
Fortuna, CA 95540-7103
Related CCNs
051318

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 4

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0860685Providence Family Practice3302 Renner Dr, Fortuna, CA 95540Certificate of waiverJan 21, 2028

National Provider Directory

National Provider Directory
Tax ID family
St Joseph Health Northern California LLC21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

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

View all 20

Locations

3302 Renner Dr
Fortuna, CA 95540
Phone (707) 725-3318

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
James C Devore Individual Corporate DirectorMember, Board of Managers Jan 1, 2020
Oluyemi Adeyanju Individual Corporate OfficerVP, Sr Corporate Counsel Apr 1, 2018
Judith L Coffey Individual Corporate DirectorBoard Member May 26, 2021
Mary Bernadette McNulty Individual Corporate DirectorMember, Board of Managers Apr 1, 2018
Providence Health & Services - Washington Organization, Renton, WA Corporation, Non-profit Operational/Managerial Control Oct 1, 2020
Patricia Fierro Scagliotti Individual W-2 Managing EmployeeManager, Operations Jan 1, 2019
John Aryanpur Individual Corporate DirectorMember, Board of Managers Jan 1, 2020
Conrad Hewitt Individual Corporate DirectorMember, Board of Managers Apr 1, 2018
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary for Enrollment Jan 1, 2020
Keith Flamer Individual Corporate DirectorBoard Member Nov 28, 2023
Gregory David Hoffman Individual Corporate OfficerPresident/Ceo & Treasurer Oct 1, 2020
Jed Weissberg Individual Corporate DirectorBoard Member May 26, 2021
St. Joseph Health System Organization, Irvine, CA Corporation, Non-profit Other Apr 1, 2018
Laureen T Driscoll Individual Corporate OfficerChief Executive Jan 25, 2022
Pamela a Kindig Individual Corporate DirectorMember, Board of Managers Jan 1, 2020
St Joseph Health Northern California LLC Organization, Irvine, CA LLC 5% Or Greater Direct Ownership Interest Apr 1, 2018 100%
Providence St. Joseph Health Organization, Renton, WA Corporation, Non-profit Other Apr 1, 2018

Owners & managing parties with NPI records 10

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

All facility ownership & control disclosures 15

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Providence Redwood Memorial HospitalFortuna, CA, CCN 051318 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018
Providence Queen of the Valley Medical CenterNapa, CA, CCN 050009 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018
Providence St. Joseph HospitalEureka, CA, CCN 050006 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2011
Providence Redwood Memorial HospitalFortuna, CA, CCN 05Z318 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018
Providence Queen of the Valley Medical CenterNapa, CA, CCN 05T009 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018
Providence Santa Rosa Memorial HospitalSanta Rosa, CA, CCN 050174 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018
Providence Santa Rosa Memorial HospitalSanta Rosa, CA, CCN 05T174 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018
Petaluma Valley HospitalPetaluma, CA, CCN 050136 Hospital Operational/Managerial Control Jan 1, 2021
Healdsburg HospitalHealdsburg, CA, CCN 05Z321 Hospital Operational/Managerial Control Jan 1, 2021
Healdsburg HospitalHealdsburg, CA, CCN 051321 Hospital Operational/Managerial Control Jan 1, 2021
Healdsburg HospitalHealdsburg, CA, CCN 555590 Skilled nursing facility Operational/Managerial Control Jan 1, 2021
Providence Home Health SonomaSanta Rosa, CA, CCN 557433 Home health agency Other Apr 1, 2018
Providence Home Health HumboldtEureka, CA, CCN 057256 Home health agency Operational/Managerial Control Apr 1, 2018
Providence Hospice Napa ValleyNapa, CA, CCN 051537 Hospice Other Jun 1, 2020
Providence Hospice Sonoma CountyPetaluma, CA, CCN 051557 Hospice 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2018

Owned or controlled facilities with NPI records 21

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

View all 21

Facilities with the same owner 139

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 139

Change-of-ownership history 2

DateEventCounterparty
Apr 1, 2018 Change of OwnershipThis provider was the buyer St. Joseph Health Rural Health ClinicCCN 058698, CA, NPI 1194189654
Apr 1, 2018 Change of OwnershipThis provider was the seller Providence Family PracticeCCN 058698, CA, NPI 1194189654

Practitioners & affiliated clinicians

Practitioners 4

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": "1460332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746576000000",
    "number": "1194189654",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-3059",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911103059",
            "telephone_number": "707-269-4263"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3302 RENNER DR",
            "city": "FORTUNA",
            "state": "CA",
            "postal_code": "95540",
            "telephone_number": "707-725-3318"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST. JOSEPH HEALTH",
        "enumeration_date": "2016-04-11",
        "last_updated": "2025-05-07",
        "certification_date": "2025-05-07",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1194189654",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PROVIDENCE FAMILY PRACTICE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fortuna, CA

Sources for this page

Verify at the official NPI Registry.