NPIMap

Organization Active NPI

Grays Harbor County Public Hospital District No. 1

Doing business as dba-McCleary Healthcare Clinic

  • Rural Health Clinic/Center
  • McCleary, WA
National Provider Identifier
1255401683
Registry record updated Apr 18, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
HAC.FS.00000186 Issued in WA
Legal business name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Doing business as
dba-McCleary Healthcare Clinic
Practice address
105 W Simpson Ave
McCleary, WA 98557-9657
Phone
(360) 346-2222
NPI assigned
Nov 9, 2006
Last updated
Apr 18, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 18, 2016

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

Authorized official

Name
Mrs. Renee K. Jensen
Title
Ceo
Phone
(360) 346-2222

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X HAC.FS.00000186 WA Primary

Addresses

Primary practice location

105 W Simpson Ave
McCleary, WA 98557-9657

Mailing address

600 E. Main Street
Elma, WA 98541
Phone (360) 346-2222

Other identifiers 4

IdentifierTypeStateIssuer
7105406MedicaidWA
106276OtherWAL&I
135OtherWAREGENCE PRO
106275OtherWACRIME VICTIM

Other names 1

  • dba-McCleary Healthcare 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
O20031226000146 WA Part B Supplier - Clinic/Group Practice 9032017256 Receives reassigned benefits from 158 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Elma, WA; McCleary, WA
O20100802000472 WA Part A Provider - Rural Health Clinic 9032017256 Practice locations: McCleary, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1255401683. Details of each certification follow.

Rural health clinic certification: CCN 503998

Legal name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
MCCLEARY HEALTHCARE CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 3, 1996
Last certification
Feb 22, 2017
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Incorporated
Jan 1, 1982 in WA
Enrollment address
105 W Simpson Ave
McCleary, WA 98557-9657
Related CCNs
501304

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 5

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
50D0707184McCleary Healthcare Clinic105 W Simpson Ave, MC Cleary, WA 98557Certificate of waiverApr 4, 2028

National Provider Directory

National Provider Directory

Locations

600 E Main St
Elma, WA 98541
Phone (360) 346-2222

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Kevin Todd Caserta Individual W-2 Managing EmployeeMD; May 1, 2025
Kenneth Dietrich Individual Corporate OfficerChief Medical Officer Dec 1, 2016 10%
Andrew T Hooper Individual Corporate Director May 17, 2010
OtherBoard Commissioner Jan 1, 2012
Cheryl J Cornwell Individual Corporate OfficerChief Financial Officer May 1, 2025
Brent K Meldrum Individual Corporate Director May 17, 2010
Amy E Thomason Individual Corporate Director May 17, 2010
OtherBoard Commissioner Jan 1, 2012
James Hansen Individual Operational/Managerial ControlChief Financial Officer May 1, 2018 15%
Gary Thumser Individual OtherBoard Commissioner Jan 1, 2014
Grays Harbor County Public Hospital District No 1 Organization, Elma, WA 5% Or Greater Direct Ownership Interest May 17, 2010
Operational/Managerial Control May 17, 2010

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Summit Pacific Medical Center - Swing Bed UnitElma, WA, CCN 50Z304 Hospital Operational/Managerial Control (100%) Feb 18, 2013
Summit Pacific Medical CenterElma, WA, CCN 501304 Hospital Operational/Managerial Control (5%) Jul 1, 1985
Summit Pacific Healthcare ClinicElma, WA, CCN 508560 Rural health clinic Operational/Managerial Control Feb 18, 2013
Summit Pacific Health ClinicElma, WA, CCN 508596 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 1, 2021

Owned or controlled facilities with NPI records 4

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

Facilities with the same owner 4

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

Practitioners & affiliated clinicians

Practitioners 36

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 36

NPI Registry JSON

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

{
    "created_epoch": "1163030400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1460937600000",
    "number": "1255401683",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 E. MAIN STREET",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "98541",
            "telephone_number": "360-346-2222"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 W SIMPSON AVE",
            "city": "MCCLEARY",
            "state": "WA",
            "postal_code": "985579657",
            "telephone_number": "360-346-2222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-09",
        "last_updated": "2016-04-18",
        "status": "A",
        "authorized_official_last_name": "JENSEN",
        "authorized_official_first_name": "RENEE",
        "authorized_official_middle_name": "K.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "360-346-2222",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WA",
            "license": "HAC.FS.00000186",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7105406",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I",
            "identifier": "106276",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE PRO",
            "identifier": "135",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CRIME VICTIM",
            "identifier": "106275",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "dba-McCleary Healthcare Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in McCleary, WA

Sources for this page

Verify at the official NPI Registry.