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Colville Nation Community Health Centers

Organization Active NPI Federally Qualified Health Center (FQHC) · Inchelium, WA

NPI 1679697155 · NPPES record last updated Jun 16, 2018

Key facts

NPI
1679697155
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
COLVILLE NATION COMMUNITY HEALTH CENTERS
Practice address
39 Shortcut Road
Inchelium, WA 99138-0290
Phone
(509) 722-7006
Fax
(509) 722-7021
NPI assigned
Mar 19, 2007
Organization subpart
No

Authorized official

Name
Sue Burkhart
Title
Biller
Phone
(509) 722-7006

Owners & managing parties with NPI records 4

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

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 1

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

Other NPIs with the same Medicare PAC ID 1

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

Corporate family (same tax ID) 3

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Facilities with the same owner 1

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

Practitioners 27

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

View all 27

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in WA, TX

Federally qualified health center certification: CCN 501902

Legal name
COLVILLE NATION COMMUNITY HEALTH CENTERS
Doing business as
LAKE ROOSEVELT COMMUNITY HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 24, 2007
Last certification
Mar 24, 2007
Ownership / control type
Non-profit – corporation
Organization structure
Other · Non-profit
Incorporated
Jun 2, 2017 in WA
Enrollment address
39 Short Cut Rd
Inchelium, WA 99138

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
Confederated Tribes of the Colville Reservation
Organization · Nespelem, WA 		5% Or Greater Direct Ownership Interest Jun 2, 2017
Gary Kohler
Individual 		Other Jun 2, 2017
Juanita Warren
Individual 		Limited Partnership Interest Jan 1, 2020
Other Jan 1, 2020
Kathy Picard
Individual 		Other Jan 1, 2022
Thomas J Sargent
Individual 		Corporate Officer
Chief Financial Officer		 Jun 2, 2017
Mae Stensgar
Individual 		Other Jun 2, 2017
Pam Phillips
Individual 		Other Jun 2, 2017
Colville Nation Community Health Centers
Organization · Inchelium, WA 		5% Or Greater Direct Ownership Interest Jun 2, 2017 100%
Operational/Managerial Control Jun 2, 2017 100%
Diane Tonasket
Individual 		Other Jun 2, 2017
Jasin Wellons
Individual 		Other Jun 2, 2017
Debra Wulff
Individual 		Corporate Officer
Executive Director		 Mar 10, 2023
Corporate Director
Executive Director		 Mar 10, 2023
W-2 Managing Employee
Executive Director		 Aug 30, 2021

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20171003004646 WA Part a Provider - Federally Qualified Health Center (FQHC) 8820363716 1 other NPI on this enrollment
Practice locations: Inchelium, WA
O20180208001598 TX Part B Supplier - Clinic/Group Practice 8820363716 Receives reassigned benefits from 20 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Inchelium, WA; Keller, WA

National Provider Directory

Tax ID family
Colville Nation Community (4 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Yes
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

39 Shortcut Road
Inchelium, WA 99138-0290

Mailing address

PO Box 290
Inchelium, WA 99138-0290
Phone (509) 722-7006

Other names

  • LAKE ROOSEVELT COMMUNITY HEALTH CENTERS Doing business as
  • Confederated Tribes of the Colville Reservation Former legal business name
  • Inchelium Clinic Other name

Other providers in Inchelium, WA

All providers in Inchelium, WA · Federally Qualified Health Center (FQHC) in Washington

Sources for this page

Verify at the official NPI Registry.