NPIMap

Organization Active NPI

Umpqua Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Sutherlin, OR
National Provider Identifier
1619399888
Registry record updated Jan 2, 2024
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
775 Taylor St.
Sutherlin, OR 97479
Phone
(541) 672-9596
NPI assigned
Jan 7, 2014
Last updated
Jan 2, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 2, 2024

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

775 Taylor St.
Sutherlin, OR 97479

Mailing address

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

Other practice location 1

123 Ponderosa Dr
Sutherlin, OR 97479-9812
Phone (541) 672-9596 ext. 114

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
O20141001002166 OR Part A Provider - Federally Qualified Health Center (FQHC) 0345233078 Practice locations: Sutherlin, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1619399888. Details of each certification follow.

Federally qualified health center certification: CCN 381954

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
Oct 16, 2014
Last certification
Oct 16, 2014
Ownership / control type
Non-profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
775 Taylor St.
Sutherlin, OR 97479

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
38D2298126Umpqua Community Health Inc775 Taylor St, Sutherlin, OR 97479Provider-performed microscopyJan 28, 2028

National Provider Directory

National Provider Directory
Tax ID family
Umpqua Community Health9 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 19

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

NameRoleSinceShare
Umpqua Community Health Center Inc Organization, Sutherlin, OR Non-profit Operational/Managerial Control Mar 1, 2014
Harold Hall Individual Corporate DirectorBoard Member Sep 26, 2018
Erin Helgren Individual Corporate DirectorBoard Member Jul 26, 2019
Tamara J Heppner Individual Corporate Director Feb 22, 2017
Nicholas Jones Individual Corporate DirectorBoard Member May 26, 2021
Stephen Loosley Individual Corporate DirectorBoard Member Feb 26, 2020
Nichole M Louder Individual Corporate Director Nov 30, 2016
Melanie McKee Individual W-2 Managing Employee Oct 15, 2014
Mindy M McFerrin Individual Corporate Director Mar 30, 2016
Gwendolyn K Graham Individual Corporate Director Nov 30, 2016
Keri a Winn Individual Corporate Director Mar 22, 2017
Ruth Galster Individual Corporate DirectorBoard Member 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
Michael Fieldman Individual Corporate DirectorBoard Member Jul 26, 2019
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

Owners & managing parties with NPI records 6

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

Practitioners & affiliated clinicians

Practitioners 8

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": "1389052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1704153600000",
    "number": "1619399888",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 NE KENNETH FORD DR",
            "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": "775 TAYLOR ST.",
            "city": "SUTHERLIN",
            "state": "OR",
            "postal_code": "97479",
            "telephone_number": "541-672-9596"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "123 Ponderosa Dr",
            "address_purpose": "LOCATION",
            "city": "Sutherlin",
            "state": "OR",
            "postal_code": "974799812",
            "country_code": "US",
            "telephone_number": "541-672-9596 x114",
            "fax_number": "541-464-3519",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "UMPQUA COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-07",
        "last_updated": "2024-01-02",
        "certification_date": "2024-01-02",
        "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": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sutherlin, OR

Sources for this page

Verify at the official NPI Registry.