NPIMap

Organization Active NPI

West County Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Guerneville, CA
National Provider Identifier
1598786352
Registry record updated Feb 28, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
XXXXXXX Issued in CA
Legal business name
WEST COUNTY HEALTH CENTERS, INC.
Practice address
16312 Third Street
Guerneville, CA 95446
Phone
(707) 869-2933
Fax
(707) 869-2663
NPI assigned
Jul 21, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2008

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

Authorized official

Name
Miss Tari M Wallace
Title
Billing Manager
Phone
(707) 869-5977

Specialties & licenses 1

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

Addresses

Primary practice location

16312 Third Street
Guerneville, CA 95446

Mailing address

PO Box 1449
Guerneville, CA 95446-1449
Phone (707) 869-2933

Other identifiers 1

IdentifierTypeStateIssuer
FHC70957FMedicaidCA

Other names 1

  • Russian River Health Center Building #2 Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070723000910 CA Part A Provider - Federally Qualified Health Center (FQHC) 6800782277 Practice locations: Guerneville, CA

Federally qualified health center certification: CCN 051100

Legal name
WEST COUNTY HEALTH CENTERS, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 27, 2007
Last certification
Aug 27, 2007
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 20, 1973 in CA
Enrollment address
16312 Third St
Guerneville, CA 95446-1449

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
West County Health Cent9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Howard John Kornfeld Individual Corporate Director Feb 1, 2000
Diane Spain Individual Corporate OfficerBoard Member Jan 28, 2013
Corporate DirectorBoard Member Feb 1, 2000
Jason Lee Cunningham Individual Corporate DirectorChief Executive Officer Mar 5, 2020
Mary S Felton Individual Corporate OfficerBoard Member Jan 28, 2013
Corporate DirectorBoard Member Feb 1, 2000
Robert W Heinemeier Individual Contracted Managing EmployeeChief Financial Officer Jun 1, 2020
Henry P Hamlin Individual Corporate Director Feb 1, 2000
Dwight Cary Individual Corporate OfficerBoard Member Feb 1, 2000
Corporate DirectorBoard Member Feb 1, 2000
Alan H Siegle Individual Corporate OfficerBoard Member Jan 28, 2013
Corporate Director Feb 1, 2000
Ila K Sheridan Individual Corporate DirectorBoard Member Feb 1, 2000
Debra Johnson Individual Corporate DirectorBoard Member Feb 1, 2000

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 22

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

View all 22

NPI Registry JSON

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

{
    "created_epoch": "1153440000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1204156800000",
    "number": "1598786352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1449",
            "city": "GUERNEVILLE",
            "state": "CA",
            "postal_code": "954461449",
            "telephone_number": "707-869-2933",
            "fax_number": "707-869-2663"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16312 THIRD STREET",
            "city": "GUERNEVILLE",
            "state": "CA",
            "postal_code": "95446",
            "telephone_number": "707-869-2933",
            "fax_number": "707-869-2663"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WEST COUNTY HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-21",
        "last_updated": "2008-02-28",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "TARI",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "707-869-5977",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "XXXXXXX",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70957F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Russian River Health Center Building #2",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Guerneville, CA

Sources for this page

Verify at the official NPI Registry.