NPIMap

Organization Active NPI

Grays Harbor County Public Hospital District No. 1

Doing business as Summit Pacific Wellness Clinic

  • Rural Health Clinic/Center
  • Elma, WA
National Provider Identifier
1811025216
Registry record updated Jan 18, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
HAC.FS.00000186 Issued in WA
Legal business name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Doing business as
Summit Pacific Wellness Clinic
Practice address
610 E Main Street
Elma, WA 98541-9551
Phone
(360) 346-2222
Fax
(360) 346-2163
NPI assigned
Feb 28, 2007
Last updated
Jan 18, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 18, 2019

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

Authorized official

Name
Mrs. Renee K Jensen
Title
Ceo
Phone
(360) 495-3244

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X HAC.FS.00000186 WA Primary
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

610 E Main Street
Elma, WA 98541-9551

Mailing address

600 E Main St
Elma, WA 98541-9560
Phone (360) 346-2222

Other identifiers 1

IdentifierTypeStateIssuer
7103815MedicaidWA

Other names 1

  • Summit Pacific Wellness Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031226000146 WA Part B Supplier - Clinic/Group Practice 9032017256 Receives reassigned benefits from 158 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Elma, WA; McCleary, WA
O20101105000276 WA Part A Provider - Rural Health Clinic 9032017256 Practice locations: Elma, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811025216. Details of each certification follow.

Rural health clinic certification: CCN 508556

Legal name
GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO 1
Doing business as
ELMA FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 15, 2011
Last certification
Aug 1, 2024
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Incorporated
Jan 1, 1982 in WA
Enrollment address
575 E Main St BLDG 2
Elma, WA 98541-9551
Related CCNs
501304

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 5

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

National Provider Directory

National Provider Directory
Tax ID family
Grays Harbor County Public3 organizations share this tax ID, including this one
Part of
Grays Harbor County Public

Other organizations with this tax ID 2

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

Locations

401 W Anderson St
Elma, WA 98541
Phone (360) 482-3711

105 W Simpson Ave
McCleary, WA 98557
Phone (360) 346-2222

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
Andrew T Hooper Individual Corporate Director Mar 27, 2008
Joshua Martin Individual Operational/Managerial ControlCeo Apr 10, 2017 100%
James Hansen Individual Corporate OfficerCfo May 1, 2018 10%
Operational/Managerial ControlCfo May 1, 2018 10%

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
Summit Pacific Medical Center - Swing Bed UnitElma, WA, CCN 50Z304 Hospital Operational/Managerial Control (100%) Feb 18, 2013
Summit Pacific Medical CenterElma, WA, CCN 501304 Hospital Operational/Managerial Control (5%) Jul 1, 1985
McCleary Healthcare ClinicMcCleary, WA, CCN 503998 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 May 17, 2010
May 17, 2010
Summit Pacific Healthcare ClinicElma, WA, CCN 508560 Rural health clinic Operational/Managerial Control Feb 18, 2013
Summit Pacific Health ClinicElma, WA, CCN 508596 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 1, 2021

Owned or controlled facilities with NPI records 5

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

Practitioners & affiliated clinicians

Practitioners 41

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 41

NPI Registry JSON

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

{
    "created_epoch": "1172620800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547769600000",
    "number": "1811025216",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 E MAIN ST",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "985419560",
            "telephone_number": "360-346-2222",
            "fax_number": "360-346-2163"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "610 E MAIN STREET",
            "city": "ELMA",
            "state": "WA",
            "postal_code": "985419551",
            "telephone_number": "360-346-2222",
            "fax_number": "360-346-2163"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1",
        "enumeration_date": "2007-02-28",
        "last_updated": "2019-01-18",
        "status": "A",
        "authorized_official_last_name": "JENSEN",
        "authorized_official_first_name": "RENEE",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "360-495-3244",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "WA",
            "license": "HAC.FS.00000186",
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7103815",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Summit Pacific Wellness Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Summit Pacific Wellness Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elma, WA

Sources for this page

Verify at the official NPI Registry.