NPIMap

Organization Active NPI

Colville Nation Community Health Centers

Doing business as Lake Roosevelt Community Health Centers

  • Federally Qualified Health Center (FQHC)
  • Inchelium, WA
National Provider Identifier
1679697155
Registry record updated Jun 16, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COLVILLE NATION COMMUNITY HEALTH CENTERS
Doing business as
Lake Roosevelt 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
Last updated
Jun 16, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2018

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

Authorized official

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

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
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 3

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA, TX2 enrollments

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679697155. Details of each certification follow.

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
OtherNon-profit
Incorporated
Jun 2, 2017 in WA
Enrollment address
39 Short Cut Rd
Inchelium, WA 99138

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Colville Nation Community4 organizations share this tax ID, including this one

Other organizations with this 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.

Ownership & related parties

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 OfficerChief 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 OfficerExecutive Director Mar 10, 2023
Corporate DirectorExecutive Director Mar 10, 2023
W-2 Managing EmployeeExecutive Director Aug 30, 2021

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.

Facilities with the same owner 1

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

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1174262400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1529107200000",
    "number": "1679697155",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 290",
            "city": "INCHELIUM",
            "state": "WA",
            "postal_code": "991380290",
            "telephone_number": "509-722-7006",
            "fax_number": "509-722-7021"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "39 SHORTCUT ROAD",
            "city": "INCHELIUM",
            "state": "WA",
            "postal_code": "991380290",
            "telephone_number": "509-722-7006",
            "fax_number": "509-722-7021"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLVILLE NATION COMMUNITY HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-19",
        "last_updated": "2018-06-16",
        "status": "A",
        "authorized_official_last_name": "BURKHART",
        "authorized_official_first_name": "SUE",
        "authorized_official_title_or_position": "BILLER",
        "authorized_official_telephone_number": "509-722-7006"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LAKE ROOSEVELT COMMUNITY HEALTH CENTERS",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Confederated Tribes of the Colville Reservation",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "INCHELIUM CLINIC",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Inchelium Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Inchelium, WA

Sources for this page

Verify at the official NPI Registry.