NPIMap

Organization Active NPI

Port Gamble S'Klallam Tribe

  • Federally Qualified Health Center (FQHC)
  • Kingston, WA
National Provider Identifier
1760428650
Registry record updated Jan 7, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PORT GAMBLE S'KLALLAM TRIBE
Practice address
32014 Little Boston Rd NE
Kingston, WA 98346-9734
Phone
(360) 297-9601
Fax
(360) 297-9614
NPI assigned
Jun 21, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 7, 2011

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

Authorized official

Name
Dallas I Deguire
Title
Administrative Director
Phone
(360) 297-9601

Specialties & licenses 1

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

Addresses

Primary practice location

32014 Little Boston Rd NE
Kingston, WA 98346-9734

Mailing address

32014 Little Boston Rd NE
Kingston, WA 98346-9734
Phone (360) 297-9601

Other identifiers 8

IdentifierTypeStateIssuer
1980929MedicaidWA
1992825MedicaidWA
5031810MedicaidWA
7094964MedicaidWA
7094972MedicaidWA
PO1021OtherWAREGENCE RIDER#
0101820OtherWAL&I CLINIC ID#
5031794MedicaidWA

Other names 1

  • Port Gamble S'Klallam Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040115001158 WA Part B Supplier - Clinic/Group Practice 6204737927 Receives reassigned benefits from 25 practitioners
Practice locations: Kingston, WA
O20100827000443 WA Part A Provider - Federally Qualified Health Center (FQHC) 6204737927 Practice locations: Kingston, WA

Federally qualified health center certification: CCN 501839

Legal name
PORT GAMBLE S'KLALLAM TRIBE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 18, 1995
Last certification
Jul 18, 1995
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
32020 Little Boston Rd NE
Kingston, WA 98346-9734

Other NPIs with the same Medicare PAC ID 1

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

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
50D0722309Port Gamble S'Klallam Clinic32020 Little Boston Road NE, Kingston, WA 98346Provider-performed microscopyAug 31, 2026

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

32020 Little Boston Rd NE
Kingston, WA 98346
Phone (360) 297-2840

32010 Little Boston Rd NE
Kingston, WA 98346

31912 Little Boston Rd NE
Kingston, WA 98346
Phone (360) 297-6329

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Jolene Sullivan Individual Corporate DirectorHealth Services Director Jan 1, 2019 100%
Operational/Managerial ControlHealth Services Director Jan 1, 2019 100%
Port Gamble S'Klallam Tribe Organization, Kingston, WA Operational/Managerial Control Jul 1, 2010
Destiny Oliver Individual Corporate Director Jan 1, 2022
Operational/Managerial ControlAdm Director Tribal SVCS Jan 1, 2022 100%

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 53

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

View all 53

NPI Registry JSON

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

{
    "created_epoch": "1150848000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1294358400000",
    "number": "1760428650",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "32014 LITTLE BOSTON RD NE",
            "city": "KINGSTON",
            "state": "WA",
            "postal_code": "983469734",
            "telephone_number": "360-297-9601",
            "fax_number": "360-297-9614"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "32014 LITTLE BOSTON RD NE",
            "city": "KINGSTON",
            "state": "WA",
            "postal_code": "983469734",
            "telephone_number": "360-297-9601",
            "fax_number": "360-297-9614"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT GAMBLE S'KLALLAM TRIBE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-21",
        "last_updated": "2011-01-07",
        "status": "A",
        "authorized_official_last_name": "DEGUIRE",
        "authorized_official_first_name": "DALLAS",
        "authorized_official_middle_name": "I",
        "authorized_official_title_or_position": "ADMINISTRATIVE DIRECTOR",
        "authorized_official_telephone_number": "360-297-9601"
    },
    "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": "1980929",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1992825",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5031810",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7094964",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7094972",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE RIDER#",
            "identifier": "PO1021",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I CLINIC ID#",
            "identifier": "0101820",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5031794",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Port Gamble S'Klallam Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kingston, WA

Sources for this page

Verify at the official NPI Registry.