NPIMap

Organization Active NPI

West County Health Centers, Inc.

Doing business as Gravenstein South

  • Federally Qualified Health Center (FQHC)
  • Sebastopol, CA
National Provider Identifier
1841916889
Registry record updated Oct 12, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WEST COUNTY HEALTH CENTERS, INC.
Doing business as
Gravenstein South
Practice address
652 Petaluma Ave Ste C-F
Sebastopol, CA 95472-4256
Phone
(707) 874-8231
NPI assigned
Oct 12, 2022
Last updated
Oct 12, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2022

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

Authorized official

Name
Vikki Minnifield
Title
Billing Manager
Phone
(707) 271-7052

Specialties & licenses 1

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

Addresses

Primary practice location

652 Petaluma Ave Ste C-F
Sebastopol, CA 95472-4256

Mailing address

PO Box 1449
Guerneville, CA 95446-1449
Phone (707) 271-7052

Other names 1

  • Gravenstein South Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221202000792 CA Part A Provider - Federally Qualified Health Center (FQHC) 6800782277 Practice locations: Sebastopol, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1841916889. Details of each certification follow.

Federally qualified health center certification: CCN A01129

Legal name
WEST COUNTY HEALTH CENTERS, INC.
Doing business as
GRAVENSTEIN SOUTH HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 4, 2022
Last certification
Nov 4, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 20, 1973 in CA
Enrollment address
652 Petaluma Ave
Ste C-F
Sebastopol, CA 95472-4266

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
Jennifer Williamsmd9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

6550 Front St
Forestville, CA 95436
Phone (707) 887-0290

652 Petaluma Ave
Ste Cf
Sebastopol, CA 95472
Phone (707) 823-3266

6800 Palm Ave
Ste C2
Sebastopol, CA 95472
Phone (707) 823-7616

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Howard John Kornfeld Individual Corporate DirectorBoard Member Mar 1, 2013
Jason Lee Cunningham Individual Corporate OfficerChief Executive Officer Mar 5, 2020
Mary S Felton Individual Corporate DirectorBoard Member Mar 1, 2013
Robert W Heinemeier Individual Contracted Managing EmployeeChief Financial Officer Jun 1, 2020
Corporate OfficerChief Financial Officer Jun 1, 2020
Henry P Hamlin Individual Corporate DirectorBoard Member Mar 1, 2013
Dwight Cary Individual Corporate DirectorBoard Memeber Mar 1, 2013
Alan H Siegle Individual Corporate DirectorBoard Member Mar 1, 2013
Debra Johnson Individual Corporate DirectorBoard Member Mar 1, 2013

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 19

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 19

NPI Registry JSON

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

{
    "created_epoch": "1665532800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665532800000",
    "number": "1841916889",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1449",
            "city": "GUERNEVILLE",
            "state": "CA",
            "postal_code": "954461449",
            "telephone_number": "707-271-7052"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "652 PETALUMA AVE STE C-F",
            "city": "SEBASTOPOL",
            "state": "CA",
            "postal_code": "954724256",
            "telephone_number": "707-874-8231"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WEST COUNTY HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-12",
        "last_updated": "2022-10-12",
        "certification_date": "2022-10-12",
        "status": "A",
        "authorized_official_last_name": "MINNIFIELD",
        "authorized_official_first_name": "VIKKI",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "707-271-7052"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Gravenstein South",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sebastopol, CA

Sources for this page

Verify at the official NPI Registry.