NPIMap

Organization Active NPI

SHC Medical Center Toppenish

Doing business as Vintage Valley Family Med

  • Rural Health Clinic/Center
  • Zillah, WA
National Provider Identifier
1659809457
Registry record updated Oct 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SHC MEDICAL CENTER TOPPENISH
Doing business as
Vintage Valley Family Med
Practice address
915 Vintage Valley Pkwy Ste 200
Zillah, WA 98953-9800
Phone
(509) 829-5151
NPI assigned
May 24, 2017
Last updated
Oct 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2024

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

Authorized official

Name
Mathew Mathiesen
Title
Cfo
Phone
(509) 837-1379

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 600581630 WA
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

915 Vintage Valley Pkwy Ste 200
Zillah, WA 98953-9800

Mailing address

PO Box 719
Sunnyside, WA 98944-0719
Phone (509) 837-1617

Other names 1

  • Vintage Valley Family Med Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20171018001921 WA Part B Supplier - Hospital Department(S) 4082980065 Receives reassigned benefits from 81 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Toppenish, WA; Union Gap, WA; Yakima, WA; Zillah, WA
O20190109002710 WA Part A Provider - Rural Health Clinic 4082980065 Practice locations: Sunnyside, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1659809457. Details of each certification follow.

Rural health clinic certification: CCN 508581

Legal name
SHC MEDICAL CENTER TOPPENISH
Doing business as
ASTRIA HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 10, 2018
Last certification
Oct 10, 2018
Ownership / control type
2B
Most recent change of ownership
Jan 25, 2019 (1 total)
Organization structure
CorporationNon-profit
Enrollment address
1016 Tacoma Ave
Sunnyside, WA 98944-2263
Related CCNs
501330

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

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory
Tax ID family
SHC Medical Center Toppenish3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

355 Chardonnay Ave
Prosser, WA 99350
Phone (509) 781-6366

516 W 4th Ave
Toppenish, WA 98948
Phone (509) 865-1555

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
Bertha Ortega Individual Corporate OfficerChairperson Jan 1, 2021
SHC Holdco LLC Organization, Sunnyside, WA LLC, Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2017 10%
Operational/Managerial Control Sep 1, 2017 10%
Brian P Gibbons Individual Corporate DirectorPresident & Ceo Jun 1, 2024
W-2 Managing EmployeePresident & Ceo Jun 1, 2024
Matthew Mathiesen Individual Corporate DirectorChief Financial Officer Jun 1, 2024
W-2 Managing EmployeeChief Financial Officer Jun 1, 2024
Carrie Story Individual Corporate OfficerVice Chairperson Jan 1, 2021
Maxine Janis Individual Corporate OfficerBoard Member Jan 1, 2021
Catherine Bambrick Individual Corporate DirectorAdministrator Oct 1, 2021
W-2 Managing EmployeeAdministrator Oct 1, 2021
Steven Young Individual Corporate OfficerBoard Member Jan 1, 2021
Maxwell Owens Individual Corporate OfficerCfo Jan 1, 2020
Corporate DirectorCfo Jan 1, 2020
W-2 Managing EmployeeCfo Jan 1, 2020
Astria Health Organization, Sunnyside, WA Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Sep 1, 2017 90%
Operational/Managerial Control Sep 1, 2017
Other Dec 31, 2018

Facilities with the same owner 12

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

Change-of-ownership history 2

DateEventCounterparty
Jan 25, 2019 Change of OwnershipThis provider was the buyer Vintage Valley Family MedCCN 508581, WA, NPI 1659809457
Jan 25, 2019 Change of OwnershipThis provider was the seller Astria HealthCCN 508581, WA, NPI 1659809457

Practitioners & affiliated clinicians

Practitioners 31

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.

View all 31

NPI Registry JSON

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

{
    "created_epoch": "1495584000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728432000000",
    "number": "1659809457",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 719",
            "city": "SUNNYSIDE",
            "state": "WA",
            "postal_code": "989440719",
            "telephone_number": "509-837-1617"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "915 VINTAGE VALLEY PKWY STE 200",
            "city": "ZILLAH",
            "state": "WA",
            "postal_code": "989539800",
            "telephone_number": "509-829-5151"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHC MEDICAL CENTER TOPPENISH",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-24",
        "last_updated": "2024-10-09",
        "certification_date": "2024-10-09",
        "status": "A",
        "authorized_official_last_name": "MATHIESEN",
        "authorized_official_first_name": "MATHEW",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "509-837-1379"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "600581630",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Vintage Valley Family Med",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Vintage Valley Family Med",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Zillah, WA

Sources for this page

Verify at the official NPI Registry.