NPIMap

Organization Active NPI

North Canyon Medical Center, Inc

Doing business as North Canyon Jerome Clinic

  • Rural Health Clinic/Center
  • Jerome, ID
National Provider Identifier
1376160457
Registry record updated Jan 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
NORTH CANYON MEDICAL CENTER, INC
Doing business as
North Canyon Jerome Clinic
Practice address
491 Heritage Dr
Jerome, ID 83338-6701
Phone
(208) 644-7500
Fax
(208) 644-7501
NPI assigned
Jul 6, 2020
Last updated
Jan 29, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTH CANYON MEDICAL CENTER, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 29, 2021

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

Authorized official

Name
Sara Demoe
Title
Cfo
Phone
(208) 934-9695

Specialties & licenses 1

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

Addresses

Primary practice location

491 Heritage Dr
Jerome, ID 83338-6701

Mailing address

267 N Canyon Dr
Gooding, ID 83330-5500
Phone (208) 934-4433

Other names 1

  • North Canyon Jerome Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210128002378 ID Part A Provider - Rural Health Clinic 0941371439 Practice locations: Jerome, ID

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376160457. Details of each certification follow.

Rural health clinic certification: CCN 138533

Legal name
NORTH CANYON MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 8, 2021
Last certification
Jun 8, 2021
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Dec 4, 2007 in ID
Enrollment address
491 Heritage Dr
Jerome, ID 83338-6701
Related CCNs
131302

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

Other NPIs with the same Medicare PAC ID 6

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

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
13D2192417North Canyon Jerome Clinic491 Heritage Dr, Jerome, ID 83338Certificate of waiverAug 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
Partners in Healthcare Inc10 organizations share this tax ID, including this one
Part of
Partners in Healthcare Inc

Other organizations with this tax ID 9

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

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Leo Sanchez Individual Corporate Officer Aug 14, 2020 5%
Corporate Director Aug 14, 2020 5%
North Canyon Medical Center Inc Organization, Jerome, ID Non-profit Operational/Managerial Control Jan 1, 2021 100%
Sara D Demoe Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%
W-2 Managing Employee Aug 12, 2020 5%
John P Hamilton Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%
Bonnie J Marshall Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Sep 14, 2020
Elaine Bryant Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Sep 14, 2020 5%
Richard K Sanders Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%
W-2 Managing Employee Aug 12, 2020 5%
James H McCaughey Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%
Jdee M Adams Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%
W-2 Managing Employee Aug 12, 2020 5%
Operational/Managerial Control Aug 12, 2020 5%
Helen P Edwards Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%
Lucy C Osborne Individual Corporate Officer Aug 12, 2020 5%
Corporate Director Aug 12, 2020 5%

Owners & managing parties with NPI records 6

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

Practitioners & affiliated clinicians

Practitioners 2

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": "1593993600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611878400000",
    "number": "1376160457",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "267 N CANYON DR",
            "city": "GOODING",
            "state": "ID",
            "postal_code": "833305500",
            "telephone_number": "208-934-4433",
            "fax_number": "208-934-8643"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "491 HERITAGE DR",
            "city": "JEROME",
            "state": "ID",
            "postal_code": "833386701",
            "telephone_number": "208-644-7500",
            "fax_number": "208-644-7501"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH CANYON MEDICAL CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTH CANYON MEDICAL CENTER, INC.",
        "enumeration_date": "2020-07-06",
        "last_updated": "2021-01-29",
        "certification_date": "2021-01-29",
        "status": "A",
        "authorized_official_last_name": "DEMOE",
        "authorized_official_first_name": "SARA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "208-934-9695"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "North Canyon Jerome Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "North Canyon Jerome Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jerome, ID

Sources for this page

Verify at the official NPI Registry.