NPIMap

Clallam County Public Hospital District No 1

Organization Active NPI Rural Health Clinic/Center · Forks, WA

NPI 1285290338 · NPPES record last updated Aug 9, 2019

Key facts

NPI
1285290338
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Practice address
461 G St
Forks, WA 98331-9025
Phone
(360) 374-6271
Fax
(360) 374-9781
NPI assigned
May 14, 2019
Organization subpart
Yes
Parent organization (as reported)
CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1

Authorized official

Name
Carie Micheau
Title
Compliance Officer
Phone
(360) 374-6271

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Owners & managing parties with NPI records 4

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

Owned or controlled facilities with NPI records 4

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

Other NPIs on the same Medicare enrollment 4

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

Other NPIs with the same Medicare PAC ID 4

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

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

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

Facilities with the same owner 4

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

Practitioners 81

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 81

Laboratory certificates & supplier records

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D2170158Forks Family Medical Clinic
461 G St, Forks, WA 98331		Certificate of waiverApr 4, 2028

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in WA

Rural health clinic certification: CCN 508591

Legal name
CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
FORKS FAMILY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 17, 2020
Last certification
Jun 17, 2020
Ownership / control type
Non-profit – church related
Organization structure
Other · Non-profit
Enrollment address
461 G St
Forks, WA 98331-9025
Related CCNs
501325

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
Sarah Huling
Individual 		Corporate Director Jan 25, 2022
Clallam County Public Hospital District No 1
Organization · Forks, WA 		5% Or Greater Direct Ownership Interest May 1, 2012 100%
Paige Pearson
Individual 		Corporate Director Nov 12, 2024
Donald Lawley
Individual 		Corporate Director Oct 23, 2007
Carie Micheau
Individual 		W-2 Managing Employee Dec 17, 2019
Charles Carlson
Individual 		Corporate Director Jan 1, 2024
Heidi L Anderson
Individual 		Corporate Officer
Chief Executive Officer		 May 19, 2020
W-2 Managing Employee May 19, 2020
Paul Babcock
Individual 		Corporate Officer
Chief Financial Officer		 Jan 17, 2017
W-2 Managing Employee Jan 17, 2017
Amy Ruble
Individual 		Corporate Director Jan 1, 2024

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Forks Community Hospital
Forks, WA · CCN 501325		 Hospital Operational/Managerial Control Oct 23, 2007
Forks Community Hospital
Forks, WA · CCN 50Z325		 Hospital Operational/Managerial Control Oct 23, 2007
Clallam Bay Medical Clinic
Clallam Bay, WA · CCN 503975		 Rural health clinic Operational/Managerial Control Jul 7, 2008
Bogachiel Clinic
Forks, WA · CCN 508520		 Rural health clinic Operational/Managerial Control Aug 26, 2008

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040219000309 WA Part B Supplier - Clinic/Group Practice 1557256468 Receives reassigned benefits from 37 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clallam Bay, WA; Forks, WA
O20190624000999 WA Part a Provider - Rural Health Clinic 1557256468 Practice locations: Forks, WA

National Provider Directory

Part of
Clallma County Hosp Dis

Locations

590 Bogachiel Way
Forks, WA 98331
Phone (360) 374-6271

109 N Oak St
Port Angeles, WA 98362
Phone (360) 207-4727

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician
Group: 193400000X SINGLE SPECIALTY GROUP		 207Q00000X
Rural Health Clinic/Center 261QR1300X Yes

Addresses

Primary practice location

461 G St
Forks, WA 98331-9025

Mailing address

530 Bogachiel Way
Forks, WA 98331-9120
Phone (360) 374-6271

Other names

  • Forks Family Medical Clinic Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Aug 9, 2019.

{
    "created_epoch": "1557792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1565308800000",
    "number": "1285290338",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "530 BOGACHIEL WAY",
            "city": "FORKS",
            "state": "WA",
            "postal_code": "983319120",
            "telephone_number": "360-374-6271",
            "fax_number": "360-374-9781"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "461 G ST",
            "city": "FORKS",
            "state": "WA",
            "postal_code": "983319025",
            "telephone_number": "360-374-6271",
            "fax_number": "360-374-9781"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "enumeration_date": "2019-05-14",
        "last_updated": "2019-08-09",
        "status": "A",
        "authorized_official_last_name": "MICHEAU",
        "authorized_official_first_name": "CARIE",
        "authorized_official_title_or_position": "COMPLIANCE OFFICER",
        "authorized_official_telephone_number": "360-374-6271"
    },
    "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Forks Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Forks Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Forks, WA

All providers in Forks, WA · Rural Health Clinic/Center in Washington

Sources for this page

Verify at the official NPI Registry.