Adapt
Organization Active NPI Federally Qualified Health Center (FQHC) · Roseburg, OR
NPI 1861967648 · NPPES record last updated Apr 12, 2022
Key facts
- NPI
- 1861967648
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- ADAPT
- Practice address
- 621 W Madrone St
Roseburg, OR 97470-3090 - Phone
- (541) 492-4550
- Fax
- (541) 492-4553
- NPI assigned
- Oct 9, 2018
- Organization subpart
- Yes
- Parent organization (as reported)
- ADAPT
Authorized official
- Name
- Michelle Monet Watson
- Title
- Chief Operations Officer
- Phone
- (541) 492-4550
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 9
Other NPIs with the same Medicare PAC ID 6
Practitioners 49
-
Laurance Walter Choate, M.D.
-
Jayson Clark, MSMFT, LPC
-
Susan Ellis, PMHNP
-
Jennie L Gohman, NP
-
Christina Marie Brakebill, RN, FNP-BC
-
Mandilynn Kay McClain, M.S.
-
Emily Tucker, LPC NCC
-
Haley Rae Danskey Huse, MSN, APRN-FNP-C
-
Karen Darnell, PA-C
-
Marcy Ellen Dean, NP
-
Suzanne Ruth Dudek Dewbre, FNP-C
-
Michelle Ellsworth, LCSW
-
Barbara Farrand, LPC
-
Kimie Ann Frakes, LCSW
-
Jaime Hansen, FNP-C, FNP-BC
-
Susan Carol Hibbs, PMHNP, APRN
-
Toni Lynn Hurlocker, PMHNP-BC
-
Lindsay Rose Iannone, PA-C, MSPAS
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in OR
Federally qualified health center certification: CCN 381003
- Legal name
- ADAPT
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jun 2, 2022
- Last certification
- Jun 2, 2022
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 1, 1971 in OR
- Enrollment address
- 621 W Madrone St
Roseburg, OR 97470-3090
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| David S Rutter |
Corporate Director |
Sep 1, 2008 | |
| Gregory S Brigham |
Corporate Officer |
Sep 4, 2013 | |
| Todd C Munsey |
Corporate Director |
Jul 1, 2000 | |
| Dan Wilson |
Corporate Director | Jun 1, 2019 | |
| Kelsey L Wood |
Corporate Director |
Mar 1, 2013 | |
| Jason Harmon |
Corporate Director |
Mar 1, 2022 | |
| Judith Martin |
Corporate Director |
Jan 1, 2020 | |
| Matt Brady |
Corporate Director |
Mar 1, 2022 | |
| Michelle M Watson |
Corporate Officer |
Aug 26, 1996 | |
| Neal S Brown |
Corporate Director |
Apr 1, 2002 | |
| Deborah Phillips |
W-2 Managing Employee |
Jun 1, 1998 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Southriver Medical Clinic |
Federally qualified health center | Operational/Managerial Control (100%) | Oct 28, 2009 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20061121000327 | OR | Part B Supplier - Clinic/Group Practice | 4587662887 |
Receives reassigned benefits from 87 practitioners 9 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Bandon, OR; Winston, OR; Roseburg, OR; North Bend, OR; Brookings, OR |
| O20220602000901 | OR | Part a Provider - Federally Qualified Health Center (FQHC) | 4587662887 | Practice locations: Roseburg, OR |
National Provider Directory
- Part of
- Adapt
Locations
548 SE Jackson St
Ste 3
Roseburg, OR 97470
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
621 W Madrone St
Roseburg, OR 97470-3090
Mailing address
PO Box 1121
Roseburg, OR 97470-0254
Phone (541) 492-4550
Other practice location 1
671 SW Main St
Winston, OR 97496-6571
Phone (541) 492-4550
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 276245 | Medicaid | OR |
Other providers in Roseburg, OR
- Adapt
- Adapt
- Adapt
- Adapt
- Adapt
- Adapt
- Adapt
- Tracy Renee Adevai
- Advanced Sleep Health, LLC
- Advantage Home Care of Douglas County, Inc.
All providers in Roseburg, OR · Federally Qualified Health Center (FQHC) in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 12, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.