NPIMap

Organization Active NPI

Pacific County Hospital District 2

Doing business as Willapa Harbor Hospital

  • Critical Access Hospital
  • South Bend, WA
National Provider Identifier
1295708683
Registry record updated Jun 12, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
Legal business name
PACIFIC COUNTY HOSPITAL DISTRICT 2
Doing business as
Willapa Harbor Hospital
Practice address
800 Alder St
South Bend, WA 98586
Phone
(360) 875-5526
Fax
(360) 875-6167
NPI assigned
Feb 8, 2006
Last updated
Jun 12, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2012

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

Authorized official

Name
Mr. Terry Stone
Title
Cfo
Phone
(360) 875-4508

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X Primary

Addresses

Primary practice location

800 Alder St
South Bend, WA 98586

Mailing address

PO Box 438
800 Alder St
South Bend, WA 98586
Phone (360) 875-5526

Other names 1

  • Willapa Harbor Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040120000991 WA Part B Supplier - Clinic/Group Practice 8224939301 Receives reassigned benefits from 105 practitioners
Practice locations: South Bend, WA
O20070621000674 WA Part A Provider - Critical Access Hospital 8224939301 Receives reassigned benefits from 141 practitioners
Practice locations: South Bend, WA
O20080828000534 WA Part A Provider - Critical Access Hospital 8224939301 Practice locations: South Bend, WA

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1295708683. Details of each certification follow.

Hospital certification: CCN 501303

Legal name
PACIFIC COUNTY HOSPITAL DISTRICT 2
Doing business as
WILLAPA HARBOR HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Apr 1, 2000
Last certification
Oct 18, 2023
Beds
25 (15 certified)
Ownership / control type
Hospital district or authority
Organization structure
OtherNon-profit
Incorporated
Jun 1, 1954 in WA
Enrollment address
800 Alder St
South Bend, WA 98586-4900

Hospital certification: CCN 50Z303

Legal name
PACIFIC COUNTY HOSPITAL DISTRICT 2
Doing business as
WILLAPA HARBOR HOSPITAL
Organization structure
OtherNon-profit
Incorporated
Jun 1, 1954 in WA
Enrollment address
800 Alder St
South Bend, WA 98586-4900

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

Other NPIs with the same Medicare PAC ID 1

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Willapa Harbor HospitalCCN 501303 · All quality measures
Type
Critical Access Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

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
50D0637271Willapa Harbor Hospital Laboratory800 Alder St, South Bend, WA 98586ComplianceApr 4, 2028

National Provider Directory

National Provider Directory

Locations

151 S Sunrise Way
Ste 400
Palm Springs, CA 92262
Phone (760) 674-3583

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Kimberly Polanco Individual Corporate OfficerCfo Apr 24, 2023
Matthew B Kempton Individual Corporate OfficerCeo Dec 2, 2019 100%
W-2 Managing EmployeeCeo Dec 2, 2019
Corporate OfficerCeo Dec 1, 2019
W-2 Managing EmployeeCeo Dec 1, 2019
Pacific County Hospital District 2 Organization, South Bend, WA Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 1966 100%

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 252

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 252

Affiliated clinicians 83

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 83

NPI Registry JSON

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

{
    "created_epoch": "1139356800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1339459200000",
    "number": "1295708683",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 438",
            "address_2": "800 ALDER ST",
            "city": "SOUTH BEND",
            "state": "WA",
            "postal_code": "98586",
            "telephone_number": "360-875-5526",
            "fax_number": "360-875-6167"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 ALDER ST",
            "city": "SOUTH BEND",
            "state": "WA",
            "postal_code": "98586",
            "telephone_number": "360-875-5526",
            "fax_number": "360-875-6167"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PACIFIC COUNTY HOSPITAL DISTRICT 2",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-08",
        "last_updated": "2012-06-12",
        "status": "A",
        "authorized_official_last_name": "STONE",
        "authorized_official_first_name": "TERRY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "360-875-4508",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Willapa Harbor Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Bend, WA

Sources for this page

Verify at the official NPI Registry.