NPIMap

Organization Active NPI

Community Health Center of Snohomish County

  • Federally Qualified Health Center (FQHC)
  • Everett, WA
National Provider Identifier
1669504395
Registry record updated Aug 12, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
7034036 Issued in WA
Legal business name
COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Practice address
1019 112TH St SW
Everett, WA 98204
Phone
(425) 551-6200
Fax
(425) 551-6017
NPI assigned
Mar 9, 2007
Last updated
Aug 12, 2011By the provider in NPPES
Organization subpart
Yes
Parent organization
COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 12, 2011

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

Authorized official

Name
Mr. Robert C Farrell
Title
Executive Director
Phone
(425) 789-3700

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 7034036 WA Primary
Family Medicine Physician 207Q00000X 7034036 WA

Addresses

Primary practice location

1019 112TH St SW
Everett, WA 98204

Mailing address

PO Box 13060
Everett, WA 98206-3060
Phone (425) 789-3700

Other identifiers 3

IdentifierTypeStateIssuer
7034036MedicaidWA
8934243OtherWACRIME VICTIMS COMP
32770OtherWAWORKER COMPENSATION

Other names 1

  • CHC of Snohomish County 112th Medical Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070717000736 WA Part A Provider - Federally Qualified Health Center (FQHC) 0446152003 Practice locations: Everett, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669504395. Details of each certification follow.

Federally qualified health center certification: CCN 501851

Legal name
COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 1, 1999
Last certification
Jul 1, 1999
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 21, 1984 in WA
Enrollment address
1019 112TH St SW
Everett, WA 98204-4875

Other NPIs with the same Medicare PAC ID 17

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

View all 17

National Provider Directory

National Provider Directory
Tax ID family
Comm HLTH Ctr Snohomis Cty29 organizations share this tax ID, including this one
Part of
Comm HLTH Ctr Snohomis Cty

Other organizations with this tax ID 28

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

View all 28

Locations

1019 112th St SW
Everett, WA 98204
Phone (425) 551-6001

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
Julian King Individual Corporate OfficerBoard Member Jan 1, 2020
Dion C Kapetanov Individual W-2 Managing EmployeeCao-Chief Administrator Officer Dec 1, 2010
Joseph E Vessey Individual Corporate OfficerCeo Dec 1, 2019
W-2 Managing EmployeeCeo Dec 1, 2019
Robert Maxwell Individual Corporate OfficerBoard Member Jan 1, 2020
Sandra Toussaint Individual Corporate OfficerBoard Member Jan 1, 2020
Charles Mister Individual Corporate OfficerBoard Member Jan 1, 2020
Edward Rogan Individual Corporate OfficerBoard Member Dec 1, 2016
Olivia D Mathisen-Holloman Individual Corporate OfficerBoard Chair Feb 1, 2017
Joel a Emery Individual Corporate OfficerCfo Feb 5, 2024
W-2 Managing EmployeeCfo Feb 5, 2024
Jessica Enick Individual Corporate OfficerActing Chair Jan 1, 2020

NPI Registry JSON

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

{
    "created_epoch": "1173398400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1313107200000",
    "number": "1669504395",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 13060",
            "city": "EVERETT",
            "state": "WA",
            "postal_code": "982063060",
            "telephone_number": "425-789-3700",
            "fax_number": "425-789-3750"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1019 112TH ST SW",
            "city": "EVERETT",
            "state": "WA",
            "postal_code": "98204",
            "telephone_number": "425-551-6200",
            "fax_number": "425-551-6017"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY",
        "enumeration_date": "2007-03-09",
        "last_updated": "2011-08-12",
        "status": "A",
        "authorized_official_last_name": "FARRELL",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "425-789-3700",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "WA",
            "license": "7034036",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "7034036",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7034036",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CRIME VICTIMS COMP",
            "identifier": "8934243",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WORKER COMPENSATION",
            "identifier": "32770",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CHC of Snohomish County 112th Medical",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Everett, WA

Sources for this page

Verify at the official NPI Registry.