NPIMap

Organization Active NPI

Umpqua Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Myrtle Creek, OR
National Provider Identifier
1508018946
Registry record updated Jun 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
UMPQUA COMMUNITY HEALTH CENTER, INC.
Practice address
790 S. Main
Myrtle Creek, OR 97457
Phone
(541) 860-4070
Fax
(541) 860-5032
NPI assigned
Oct 16, 2008
Last updated
Jun 28, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 28, 2022

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

Authorized official

Name
KC Bolton
Title
Ceo
Phone
(541) 672-9596

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

790 S. Main
Myrtle Creek, OR 97457

Mailing address

150 Kenneth Ford Drive
Roseburg, OR 97470-1042
Phone (541) 672-9596

Other identifiers 1

IdentifierTypeStateIssuer
168395MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040511000463 OR Part B Supplier - Clinic/Group Practice 0345233078 Receives reassigned benefits from 56 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Roseburg, OR; Sutherlin, OR; Myrtle Creek, OR; Glide, OR; Drain, OR
O20090811000539 OR Part A Provider - Federally Qualified Health Center (FQHC) 0345233078 Practice locations: Myrtle Creek, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508018946. Details of each certification follow.

Federally qualified health center certification: CCN 381918

Legal name
UMPQUA COMMUNITY HEALTH CENTER INC
Doing business as
OPEN DOOR CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 14, 2009
Last certification
Aug 14, 2009
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Nov 19, 2001 in OR
Enrollment address
790 S Main St
Myrtle Creek, OR 97457-9303

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 7

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
38D2298124Umpqua Community Health Inc790 S Main St, Myrtle Creek, OR 97457Provider-performed microscopyJan 28, 2028

National Provider Directory

National Provider Directory

Locations

2001 NW Newcastle St
Roseburg, OR 97471
Phone (540) 440-3532

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Tamara J Heppner Individual Corporate Director Feb 22, 2017
Mark M Herscher Individual Corporate DirectorBoard Member May 23, 2012
Gary Hunt Individual Corporate OfficerChief Financial Officer Oct 24, 2016
Nichole M Louder Individual Corporate Director Nov 30, 2016
Christopher Burnett Individual Corporate Director Sep 25, 2013
Melanie McKee Individual W-2 Managing Employee Oct 15, 2014
Mindy M McFerrin Individual Corporate Director Mar 30, 2016
Janet Morse Individual Corporate DirectorBoard Member Dec 1, 2010
Gwendolyn K Graham Individual Corporate Director Nov 30, 2016
Keri a Winn Individual Corporate Director Mar 22, 2017
Ruth Galster Individual Corporate Director Jul 24, 2013
Jodee Jackson Individual Corporate Director Jun 30, 2017
Charles E Ireland Individual Corporate Director Jun 27, 2018
Angela L Murphy Individual Corporate Director Oct 26, 2016
Karl C Bolton Individual Corporate OfficerChief Executive Officer Aug 23, 2016
Andrea M Miner Individual Corporate Director May 25, 2015
Leah Hamilton Individual W-2 Managing Employee Oct 19, 2017

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Open Door ClinicSutherlin, OR, CCN 381954 Federally qualified health center Operational/Managerial Control Mar 1, 2014

Owned or controlled facilities with NPI records 1

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

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": "1224115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1656374400000",
    "number": "1508018946",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 KENNETH FORD DRIVE",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974701042",
            "telephone_number": "541-672-9596",
            "fax_number": "541-464-3519"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "790 S. MAIN",
            "city": "MYRTLE CREEK",
            "state": "OR",
            "postal_code": "97457",
            "telephone_number": "541-860-4070",
            "fax_number": "541-860-5032"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UMPQUA COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-16",
        "last_updated": "2022-06-28",
        "certification_date": "2022-06-28",
        "status": "A",
        "authorized_official_last_name": "BOLTON",
        "authorized_official_first_name": "KC",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "541-672-9596"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "168395",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Myrtle Creek, OR

Sources for this page

Verify at the official NPI Registry.