NPIMap

Organization Active NPI

Clackamas County

  • Federally Qualified Health Center (FQHC)
  • Oregon City, OR
National Provider Identifier
1720017809
Registry record updated Sep 24, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CLACKAMAS COUNTY
Practice address
110 Beavercreek Rd Ste 100
Oregon City, OR 97045-4307
Phone
(503) 655-8471
Fax
(503) 655-8595
NPI assigned
Jul 1, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 24, 2019

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

Authorized official

Name
Ed Johnson
Title
Cfo
Phone
(503) 742-5325

Specialties & licenses 1

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

Addresses

Primary practice location

110 Beavercreek Rd Ste 100
Oregon City, OR 97045-4307

Mailing address

2051 Kaen Rd
Suite 367
Oregon City, OR 97045-4035
Phone (503) 742-5300

Other identifiers 1

IdentifierTypeStateIssuer
022710MedicaidOR

Other names 1

  • Beavercreek Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR7 enrollments

Enrollment records 7

Enrollment IDStateProvider typePAC IDDetails
O20031210000827 OR Part B Supplier - Clinic/Group Practice 9537065560 Receives reassigned benefits from 128 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Oregon City, OR; Sandy, OR; Milwaukie, OR; Clackamas, OR; Happy Valley, OR
O20040602000311 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Sandy, OR
O20080912000100 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 Practice locations: Oregon City, OR
O20101026001528 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gladstone, OR
O20101119000241 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Milwaukie, OR
O20120614000822 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clackamas, OR
O20130502000225 OR Part A Provider - Federally Qualified Health Center (FQHC) 9537065560 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Sandy, OR

Federally qualified health center certification: CCN 381870

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
CLACKAMAS HEALTH CENTERS - SANDY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 14, 2004
Last certification
Jun 14, 2004
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Incorporated
Jan 1, 1966 in OR
Enrollment address
39740 Pleasant St
Sandy, OR 97055-6412

Federally qualified health center certification: CCN 381820

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
CLACKAMAS HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 13, 1993
Last certification
Sep 13, 1993
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Incorporated
Jan 1, 1990 in OR
Enrollment address
110 Beavercreek Rd
Ste 100
Oregon City, OR 97045-4307

Federally qualified health center certification: CCN 381923

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
CLACKAMAS HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 1, 2010
Last certification
Nov 1, 2010
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
18911 Portland Ave
Gladstone, OR 97027-1630

Federally qualified health center certification: CCN 381922

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
LAKE ROAD HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 22, 2010
Last certification
Nov 22, 2010
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
6605 SE Lake Rd
Milwaukie, OR 97222-2161

Federally qualified health center certification: CCN 381931

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
CLACKAMAS HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 14, 2012
Last certification
Jun 14, 2012
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
9775 SE Sunnyside Rd
Ste 200
Clackamas, OR 97015-5721

Federally qualified health center certification: CCN 381936

Legal name
COUNTY OF CLACKAMAS OFFICE OF COUNTY AUDITOR
Doing business as
CLACKAMAS HEALTH CENTERS - SANDY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 4, 2013
Last certification
Apr 4, 2013
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Incorporated
Jan 1, 1990 in OR
Enrollment address
39740 Pleasant St
Sandy, OR 97055-6412

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 6

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
38D0662552Clackamas Health Centers110 Beavercreek Road Suite 100, Oregon City, OR 97045Provider-performed microscopyDec 31, 2027

National Provider Directory

National Provider Directory

Locations

14486 SE 122nd Ave
Clackamas, OR 97015
Phone (503) 353-5800

110 Beavercreek Rd
Ste 100
Oregon City, OR 97045

2051 Kaen Rd
#398
Oregon City, OR 97045

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Morgan Fetzer Individual W-2 Managing EmployeeAdministrative Assistant Mar 1, 2015
W-2 Managing EmployeeCredentialing/Compliance Assistant Mar 1, 2015
Sarah Jacobson Individual W-2 Managing EmployeeOffice Manager Fiscal Dec 1, 2014 100%
W-2 Managing EmployeeOfffice Manager Fiscal Dec 1, 2014 100%
County of Clackamas Office of County Auditor Organization, Sandy, OR Non-profit Operational/Managerial Control Dec 13, 2010
5% Or Greater Direct Ownership Interest Jan 1, 2014 100%
Operational/Managerial Control Jan 1, 2014 100%
Operational/Managerial Control Sep 1, 2010 100%
Operational/Managerial Control Aug 28, 2006 100%
Operational/Managerial Control Jan 28, 2013 100%
Adam Kearl Individual W-2 Managing EmployeeAd; Aug 1, 2018
Corporate OfficerHealth Centers Cfo Oct 1, 2023
W-2 Managing EmployeeAd; Oct 1, 2023
Deborah S Cockrell Individual Corporate DirectorFQHC Director Aug 25, 2014 100%
Ed Johnson Individual Corporate OfficerCfo Jan 1, 2016 100%
Gina Beltran Individual W-2 Managing EmployeePolicy, Perf, Research Analyst May 22, 2019

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 6

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

FacilityTypeRoleSince
Clackamas Health Centers - Sandy ClinicSandy, OR, CCN 381870 Federally qualified health center Operational/Managerial Control Dec 13, 2010
Clackamas Health CentersGladstone, OR, CCN 381923 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2014
Sep 1, 2010
Lake Road Health CenterMilwaukie, OR, CCN 381922 Federally qualified health center Operational/Managerial Control (100%) Aug 28, 2006
Clackamas Health CentersClackamas, OR, CCN 381931 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2014
Jan 1, 2014
Clackamas Health Centers - Sandy Health ClinicSandy, OR, CCN 381936 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2014
Jan 28, 2013
Clackamas Health CentersOregon City, OR, CCN 381944 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 1990
Jan 1, 1990

Owned or controlled facilities with NPI records 6

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

Facilities with the same owner 6

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

Practitioners 89

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

View all 89

NPI Registry JSON

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

{
    "created_epoch": "1151712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1569283200000",
    "number": "1720017809",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2051 KAEN RD",
            "address_2": "SUITE 367",
            "city": "OREGON CITY",
            "state": "OR",
            "postal_code": "970454035",
            "telephone_number": "503-742-5300",
            "fax_number": "503-655-8350"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "110 BEAVERCREEK RD STE 100",
            "city": "OREGON CITY",
            "state": "OR",
            "postal_code": "970454307",
            "telephone_number": "503-655-8471",
            "fax_number": "503-655-8595"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLACKAMAS COUNTY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-01",
        "last_updated": "2019-09-24",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "ED",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "503-742-5325"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "022710",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Beavercreek Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Beavercreek Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Oregon City, OR

Sources for this page

Verify at the official NPI Registry.