NPIMap

Organization Active NPI

Waterfall Clinic, Incorporated

  • Federally Qualified Health Center (FQHC)
  • Coos Bay, OR
National Provider Identifier
1508133299
Registry record updated Feb 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WATERFALL CLINIC, INCORPORATED
Practice address
826 S 11TH St
Coos Bay, OR 97420
Phone
(541) 756-6232
Fax
(541) 756-6234
NPI assigned
Nov 23, 2011
Organization subpart
Yes
Parent organization
WATERFALL CLINIC, INCORPORATEDAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 26, 2018

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

Authorized official

Name
Ava Kathleen McFeron
Title
Ceo Asst.
Phone
(541) 435-7033

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

826 S 11TH St
Coos Bay, OR 97420

Mailing address

1890 Waite St
Ste 1
North Bend, OR 97459-1229
Phone (541) 756-6232

Other identifiers 1

IdentifierTypeStateIssuer
500647633MedicaidOR

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040827000153 OR Part B Supplier - Clinic/Group Practice 5698740355 Receives reassigned benefits from 38 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Coos Bay, OR; North Bend, OR
O20140729002307 OR Part A Provider - Federally Qualified Health Center (FQHC) 5698740355 Practice locations: Coos Bay, OR

Federally qualified health center certification: CCN 381950

Legal name
WATERFALL CLINIC INCORPORATED
Doing business as
WATERFALL SCHOOL BASED HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 29, 2014
Last certification
Jul 29, 2014
Ownership / control type
Non-profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 13, 1998 in OR
Enrollment address
826 S 11TH St
Coos Bay, OR 97420-1328

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Waterfall Community Health Center8 organizations share this tax ID, including this one
Part of
Waterfall Community Health Center

Other organizations with this tax ID 7

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
Steve Sanden Individual Corporate DirectorBoard Member Jan 1, 2024
Jordan McLaren Individual Contracted Managing EmployeeProvider Specialist/Program Manager Jan 1, 2024
Ruth Bell Individual Corporate DirectorBoard Member Jan 1, 2024
Leslie Ryan Individual Corporate DirectorBoard Secretary Jan 1, 2024
Arnold Roblan Individual Corporate DirectorBoard Treasurer Jan 1, 2025
Waterfall Clinic Incorporated Organization, North Bend, OR Non-profit 5% Or Greater Direct Ownership Interest Mar 16, 2014 100%
Brittiney Vogt Individual W-2 Managing EmployeeCredentialing Specialist Nov 1, 2024
Marcelene Knight Individual Corporate DirectorBoard Member Jan 1, 1998
Karen B Sheelar Individual Corporate OfficerCbho/Chief Behavorial Health Off Feb 1, 2023
McClain Altman Individual Corporate DirectorBoard Member Aug 1, 2020
Anna Huit Individual Corporate DirectorBoard Vice President/Chair Jan 1, 2024

Owners & managing parties with NPI records 5

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

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 21

NPI Registry JSON

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

{
    "created_epoch": "1322006400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1519603200000",
    "number": "1508133299",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1890 WAITE ST",
            "address_2": "STE 1",
            "city": "NORTH BEND",
            "state": "OR",
            "postal_code": "974591229",
            "telephone_number": "541-756-6232",
            "fax_number": "541-756-6234"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "826 S 11TH ST",
            "city": "COOS BAY",
            "state": "OR",
            "postal_code": "97420",
            "telephone_number": "541-756-6232",
            "fax_number": "541-756-6234"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATERFALL CLINIC, INCORPORATED",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WATERFALL CLINIC, INCORPORATED",
        "enumeration_date": "2011-11-23",
        "last_updated": "2018-02-26",
        "status": "A",
        "authorized_official_last_name": "MCFERON",
        "authorized_official_first_name": "AVA",
        "authorized_official_middle_name": "KATHLEEN",
        "authorized_official_title_or_position": "CEO ASST.",
        "authorized_official_telephone_number": "541-435-7033"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500647633",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Coos Bay, OR

Sources for this page

Verify at the official NPI Registry.