NPIMap

Organization Active NPI

Clallam County Public Hospital District No 1

Doing business as Forks Family Medical Clinic

  • Rural Health Clinic/Center
  • Forks, WA
National Provider Identifier
1285290338
Registry record updated Aug 9, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
Forks Family Medical Clinic
Practice address
461 G St
Forks, WA 98331-9025
Phone
(360) 374-6271
Fax
(360) 374-9781
NPI assigned
May 14, 2019
Last updated
Aug 9, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
CLALLAM COUNTY PUBLIC HOSPITAL DISTRICT NO 1As reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 9, 2019

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

Authorized official

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

Specialties & licenses 2

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

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 1

  • Forks Family Medical 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
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285290338. Details of each certification follow.

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
OtherNon-profit
Enrollment address
461 G St
Forks, WA 98331-9025
Related CCNs
501325

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

Other NPIs with the same Medicare PAC ID 4

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
50D2170158Forks Family Medical Clinic461 G St, Forks, WA 98331Certificate of waiverApr 4, 2028

National Provider Directory

National Provider Directory
Part of
Clallam Bay Medical Center

Locations

530 Bogachiel Way
Forks, WA 98331
Phone (360) 374-5011

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

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

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
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 OfficerChief Executive Officer May 19, 2020
W-2 Managing Employee May 19, 2020
Paul Babcock Individual Corporate OfficerChief Financial Officer Jan 17, 2017
W-2 Managing Employee Jan 17, 2017
Amy Ruble Individual Corporate Director Jan 1, 2024

Owners & managing parties with NPI records 4

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

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.

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.

Practitioners & affiliated clinicians

Practitioners 74

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 74

NPI Registry JSON

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

{
    "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

Sources for this page

Verify at the official NPI Registry.