NPIMap

Organization Active NPI

Klickitat County Public Hospital District No 1

Doing business as KVH Family Medicine

  • Rural Health Clinic/Center
  • Goldendale, WA
National Provider Identifier
1407952369
Registry record updated Dec 20, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
KVH Family Medicine
Practice address
317 Sanders Way
Goldendale, WA 98620-9053
Phone
(509) 773-4017
Fax
(509) 773-1941
NPI assigned
Sep 16, 2006
Last updated
Dec 20, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1As reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 20, 2021

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

Authorized official

Name
Leslie Hiebert
Title
Ceo
Phone
(509) 773-4022

Specialties & licenses 1

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

Addresses

Primary practice location

317 Sanders Way
Goldendale, WA 98620-9053

Mailing address

310 S Roosevelt Ave
Goldendale, WA 98620-9201
Phone (509) 773-4022

Other identifiers 1

IdentifierTypeStateIssuer
7113681MedicaidWA

Other names 1

  • KVH FAMILY MEDICINE Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040224000581 WA Part A Provider - Rural Health Clinic 0648164269 Practice locations: Goldendale, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407952369. Details of each certification follow.

Rural health clinic certification: CCN 508519

Legal name
KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
KVH FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 21, 2002
Last certification
Mar 16, 2015
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1941 in WA
Enrollment address
317 Sanders Way
Goldendale, WA 98620-9053
Related CCNs
501316

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).

National Provider Directory

National Provider Directory
Tax ID family
Klickitat Valley Hospit7 organizations share this tax ID, including this one
Part of
Klickitat Valley Hospit

Other organizations with this tax ID 6

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

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Larry Hoctor Individual Corporate Director Jan 15, 2020
Ronald Ihrig Individual Corporate Director Jan 3, 2022
Klickitat County Public Hospital District No 1 Organization, Goldendale, WA Non-profit Operational/Managerial Control Jan 1, 1986
Jonathan Hatfield Individual Corporate OfficerCeo Oct 7, 2023
W-2 Managing Employee Sep 6, 2005
Mary Pond Individual Corporate Director Jan 1, 2014
Crystal Scott Individual Corporate Director May 1, 2019
Mark Sigfrinius Individual Corporate Director Jan 1, 2014
Lori Groves Individual Corporate OfficerCfo Dec 1, 2020
W-2 Managing Employee Dec 1, 2020

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 1

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

FacilityTypeRoleSince
Klickitat Valley HealthGoldendale, WA, CCN 501539 Hospice Operational/Managerial Control Apr 4, 2005

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 7

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": "1158364800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1639958400000",
    "number": "1407952369",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "310 S ROOSEVELT AVE",
            "city": "GOLDENDALE",
            "state": "WA",
            "postal_code": "986209201",
            "telephone_number": "509-773-4022",
            "fax_number": "509-773-1941"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "317 SANDERS WAY",
            "city": "GOLDENDALE",
            "state": "WA",
            "postal_code": "986209053",
            "telephone_number": "509-773-4017",
            "fax_number": "509-773-1941"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "KLICKITAT COUNTY PUBLIC HOSPITAL DISTRICT NO 1",
        "enumeration_date": "2006-09-16",
        "last_updated": "2021-12-20",
        "certification_date": "2021-12-20",
        "status": "A",
        "authorized_official_last_name": "HIEBERT",
        "authorized_official_first_name": "LESLIE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "509-773-4022"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7113681",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KVH FAMILY MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "KVH FAMILY MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Goldendale, WA

Sources for this page

Verify at the official NPI Registry.