Cowlitz Family Health Center
Organization Active NPI Federally Qualified Health Center (FQHC) · Longview, WA
NPI 1962876748 · NPPES record last updated May 31, 2022
Key facts
- NPI
- 1962876748
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- License
- 600176084 (WA)
- Legal business name
- COWLITZ FAMILY HEALTH CENTER
- Practice address
- 784 14TH Ave
Longview, WA 98632-2315 - Phone
- (360) 703-6400
- Fax
- (360) 353-3611
- NPI assigned
- Nov 17, 2015
- Organization subpart
- Yes
- Parent organization (as reported)
- COWLITZ FAMILY HEALTH CENTER
Authorized official
- Name
- James K Coffee
- Title
- Ceo
- Phone
- (360) 636-3892
Other NPIs on the same Medicare enrollment 7
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 13
Practitioners 21
-
Tresha Carroll, DO
-
Gerardo R Melgar, MD
-
Seth Mercurio, NP
-
Anthony L Reyes, MD
-
Gail Conway, DO
-
Madeline Ferone, FNP-BC
-
Adreia Jenice Jessop, ARNP, CNM, IBCLC
-
Winnet Katiyo, ARNP
-
Sereyrath Lim, NP
-
Bethany L Madden, ARNP
-
Jerome March, DNP, FNP-BC
-
Sean Noel Murray, FNP-BC
-
Lisa Marie Olson, DNP, FNP
-
Diana Shields, ARNP
-
Stephanie G Wesztergom, ARNP
-
Danielle Rene Glover-Cloutier, BSN, DNP, NP-C
-
Pamela Anne Martin, ARNP
-
Marcee Stewart, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WA
Federally qualified health center certification: CCN 941018
- Legal name
- COWLITZ FAMILY HEALTH CENTER
- Doing business as
- FAMILY HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Dec 14, 2016
- Last certification
- Dec 14, 2016
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Feb 28, 1973 in WA
- Enrollment address
- 784 14TH Ave
Longview, WA 98632-2315
All disclosed owners & managing parties 4
| Name | Role | Since | Share |
|---|---|---|---|
| Wanda M McBee |
Corporate Officer |
Sep 22, 2016 | |
| James Coffee |
Corporate Officer |
Dec 1, 2020 | |
| W-2 Managing Employee |
Dec 1, 2020 | ||
| Cynthia L Washington-Mattson |
Corporate Officer |
Sep 22, 2016 | |
| Mark Nelson |
Corporate Officer |
Dec 4, 2019 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040324000330 | WA | Part B Supplier - Clinic/Group Practice | 5991696395 |
Receives reassigned benefits from 19 practitioners 7 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Castle Rock, WA; Cathlamet, WA; Kelso, WA; Longview, WA; Ocean Park, WA; Woodland, WA |
| O20161221001216 | WA | Part a Provider - Federally Qualified Health Center (FQHC) | 5991696395 | Practice locations: Longview, WA |
National Provider Directory
- Tax ID family
- NB North Beach Clinic
- Part of
- NB North Beach Clinic
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Non-Surgical Family Planning Clinic/Center | 261QF0050X | 600176084 | WA | |
| Federally Qualified Health Center (FQHC) | 261QF0400X | 600176084 | WA | Yes |
| Adult Mental Health Clinic/Center | 261QM0850X | 600176084 | WA | |
| Adolescent and Children Mental Health Clinic/Center | 261QM0855X | 600176084 | WA | |
| Primary Care Clinic/Center | 261QP2300X | 600176084 | WA |
Addresses
Primary practice location
784 14TH Ave
Longview, WA 98632-2315
Mailing address
1057 12TH Ave
Longview, WA 98632-2509
Phone (360) 636-3892
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7086523 | Medicaid | WA | |
| 1437359551 | Medicaid | WA |
Other names
- Family Health Center 14th Ave
Other providers in Longview, WA
- Cowlitz Family Health Center
- Cowlitz Family Health Center
- Cowlitz Family Health Center
- Cowlitz Family Health Center
- Cowlitz Family Health Center
- Cowlitz Indian Tribe
- Cowlitz Indian Tribe
- Cowlitz Indian Tribe
- Cowlitz Indian Tribe
- Cowlitz Indian Tribe
All providers in Longview, WA · Federally Qualified Health Center (FQHC) in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 31, 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.