NPIMap

Organization Active NPI

Winding Waters Medical Clinic

Doing business as Winding Waters Wallowa

  • Federally Qualified Health Center (FQHC)
  • Wallowa, OR
National Provider Identifier
1700453396
Registry record updated Sep 14, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WINDING WATERS MEDICAL CLINIC
Doing business as
Winding Waters Wallowa
Practice address
605 W Hwy 82
Wallowa, OR 97885-8544
Phone
(541) 426-4502
NPI assigned
Jun 10, 2021
Last updated
Sep 14, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
WINDING WATERS MEDICAL CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 14, 2023

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

Authorized official

Name
Keli Jean Dennis
Title
Coo
Phone
(541) 426-4502

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

605 W Hwy 82
Wallowa, OR 97885-8544

Mailing address

603 Medical Pkwy
Enterprise, OR 97828-5124
Phone (541) 426-4502

Other names 1

  • Winding Waters Wallowa Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220511002127 OR Part A Provider - Federally Qualified Health Center (FQHC) 8224346713 Practice locations: Wallowa, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1700453396. Details of each certification follow.

Federally qualified health center certification: CCN 381004

Legal name
WINDING WATERS MEDICAL CLINIC
Doing business as
WINDING WATERS WALLOWA
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 15, 2022
Last certification
Jun 15, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 2015 in OR
Enrollment address
605 W Hwy 82
Wallowa, OR 97885-8544

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
Winding Waters Medical Clin6 organizations share this tax ID, including this one
Part of
Winding Waters Medical Clin

Other organizations with this tax ID 5

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

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
David Flynn Individual Corporate DirectorBoard Member Apr 8, 2022
Keli Dennis Individual Corporate OfficerCoo Apr 8, 2022
W-2 Managing EmployeeCoo Apr 8, 2022
Pamela Rydstrom Latta Individual Corporate DirectorBoard Member Apr 8, 2022
Kelly Brown Individual Corporate DirectorBoard Member Apr 8, 2022
Kathleen Siebe Individual Corporate OfficerBoard Secretary Apr 8, 2022
Angie Lunde Individual Corporate OfficerBoard Chair Apr 8, 2022
Maria Weer Individual Corporate OfficerSecretary Apr 8, 2022 100%
Winding Waters Medical Clinic Organization, Wallowa, OR Medical provider/supplier, Non-profit Operational/Managerial Control Apr 8, 2022 100%
Lindsay Miller Individual Corporate OfficerBoard Vice Chair Apr 8, 2022

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Winding Waters Medical ClinicEnterprise, OR, CCN 381964 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jul 23, 2013
Winding Waters Hearts for HealthEnterprise, OR, CCN 381006 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2022
Jan 1, 2022

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 2

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

NPI Registry JSON

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

{
    "created_epoch": "1623283200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694649600000",
    "number": "1700453396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "603 MEDICAL PKWY",
            "city": "ENTERPRISE",
            "state": "OR",
            "postal_code": "978285124",
            "telephone_number": "541-426-4502"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "605 W HWY 82",
            "city": "WALLOWA",
            "state": "OR",
            "postal_code": "978858544",
            "telephone_number": "541-426-4502"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WINDING WATERS MEDICAL CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WINDING WATERS MEDICAL CLINIC",
        "enumeration_date": "2021-06-10",
        "last_updated": "2023-09-14",
        "certification_date": "2023-09-12",
        "status": "A",
        "authorized_official_last_name": "DENNIS",
        "authorized_official_first_name": "KELI",
        "authorized_official_middle_name": "JEAN",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "541-426-4502"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Winding Waters Wallowa",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Winding Waters Wallowa",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wallowa, OR

Sources for this page

Verify at the official NPI Registry.