NPIMap

Organization Active NPI

Humboldt Family Medical Care

  • Rural Health Clinic/Center
  • McKinleyville, CA
National Provider Identifier
1447287347
Registry record updated Sep 20, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
HUMBOLDT FAMILY MEDICAL CARE
Practice address
1733 Central Ave
McKinleyville, CA 95519-3601
Phone
(707) 839-4852
Fax
(707) 839-2439
NPI assigned
Jun 27, 2006
Last updated
Sep 20, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 20, 2019

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

Authorized official

Name
Douglas Allen Shaw
Title
Chief Executive Officer
Phone
(707) 822-7220

Specialties & licenses 1

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

Addresses

Primary practice location

1733 Central Ave
McKinleyville, CA 95519-3601

Mailing address

P.O. Box 4957
Arcata, CA 95518-4957
Phone (707) 822-7220

Other identifiers 3

IdentifierTypeStateIssuer
05-8505OtherCABLUE CROSS PROVIDER #
RHM53803GMedicaidCA
ZZZ67827ZOtherCABLUE SHEIRLD PROVIDER #

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090806000704 CA Part A Provider - Rural Health Clinic 9032262100 Practice locations: McKinleyville, CA
O20091009000235 CA Part B Supplier - Clinic/Group Practice 9032262100 Receives reassigned benefits from 1 practitioner
Practice locations: McKinleyville, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1447287347. Details of each certification follow.

Rural health clinic certification: CCN 058505

Legal name
HUMBOLDT FAMILY MEDICAL CARE
Doing business as
HUMBOLDT FAMILY MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 1, 1994
Last certification
Feb 26, 2015
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Jun 6, 1995 in CA
Enrollment address
1733 Central Ave
McKinleyville, CA 95519-3601
Related CCNs
050028

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

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1733 Central Ave
McKinleyville, CA 95519
Phone (707) 839-2439

1733 Central Ave
Ste A
McKinleyville, CA 95519
Phone (707) 839-4852

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
American Hospital Management Corporation Organization, Arcata, CA Corporation, Medical provider/supplier, For-profit 5% Or Greater Indirect Ownership Interest Jun 6, 1995 100%
Operational/Managerial Control Jun 6, 1995 100%
Laura McMahon Individual W-2 Managing Employee Sep 30, 2018
Doug a Shaw Individual Corporate OfficerCeo Aug 31, 2006
Corporate DirectorCeo/Administrator Aug 31, 2006

Owners & managing parties with NPI records 2

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

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 11

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": "1151366400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1568937600000",
    "number": "1447287347",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O. BOX 4957",
            "city": "ARCATA",
            "state": "CA",
            "postal_code": "955184957",
            "telephone_number": "707-822-7220",
            "fax_number": "707-826-8258"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1733 CENTRAL AVE",
            "city": "MCKINLEYVILLE",
            "state": "CA",
            "postal_code": "955193601",
            "telephone_number": "707-839-4852",
            "fax_number": "707-839-2439"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HUMBOLDT FAMILY MEDICAL CARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-27",
        "last_updated": "2019-09-20",
        "status": "A",
        "authorized_official_last_name": "SHAW",
        "authorized_official_first_name": "DOUGLAS",
        "authorized_official_middle_name": "ALLEN",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "707-822-7220"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS PROVIDER #",
            "identifier": "05-8505",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RHM53803G",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHEIRLD PROVIDER #",
            "identifier": "ZZZ67827Z",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in McKinleyville, CA

Sources for this page

Verify at the official NPI Registry.