Columbia Basin Health Association
Organization Active NPI Federally Qualified Health Center (FQHC) · Othello, WA
NPI 1992923064 · NPPES record last updated May 6, 2022
Key facts
- NPI
- 1992923064
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- License
- OD00003794 (WA)
- Legal business name
- COLUMBIA BASIN HEALTH ASSOCIATION
- Practice address
- 1515 E Columbia St
Othello, WA 99344-1846 - Phone
- (509) 488-5256
- Fax
- (509) 488-9939
- NPI assigned
- Apr 23, 2007
- Organization subpart
- No
Authorized official
- Name
- Nieves Gomez
- Title
- Ceo
- Phone
- (509) 488-5256
Other NPIs on the same Medicare enrollment 1
Corporate family (same tax ID) 16
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WA
Federally qualified health center certification: CCN 501815
- Legal name
- COLUMBIA BASIN HEALTH ASSOCIATION
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Oct 1, 1991
- Last certification
- Oct 1, 1991
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Mar 26, 1973 in WA
- Enrollment address
- 1515 E Columbia St
Othello, WA 99344-1846
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Joshua Bunch |
Corporate Officer |
Mar 1, 2018 | |
| Deborah Buss |
Corporate Officer |
Feb 26, 2013 | |
| Maria Quezada |
Corporate Director |
Mar 28, 2017 | |
| Martha Holt |
Corporate Director |
Apr 19, 2017 | |
| Nieves Gomez |
Corporate Director |
Mar 1, 2018 | 100% |
| W-2 Managing Employee |
Mar 1, 2018 | 100% | |
| Operational/Managerial Control |
Mar 1, 2018 | 100% | |
| Joe Montemayor |
Corporate Director |
Aug 26, 2010 | |
| Dora Beraza |
Corporate Director |
Aug 26, 2010 | |
| Enrique Miron |
Corporate Director |
Aug 26, 2010 | |
| Marisol Quezada |
Corporate Director |
Jan 31, 2023 | |
| Mike Garza |
Corporate Director |
Aug 26, 2010 | |
| Maria Rosales |
Corporate Director |
May 27, 2014 | |
| Scott Harris |
Corporate Director |
May 28, 2019 | |
| Martin Gallardo |
Corporate Director |
May 25, 2010 | |
| Gloria Ochoa |
Corporate Director |
Jan 31, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20101027000085 | WA | Part a Provider - Federally Qualified Health Center (FQHC) | 4486564309 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Othello, WA |
National Provider Directory
- Tax ID family
- Columbia Basin Health Association
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | WA | ||
| Federally Qualified Health Center (FQHC) | 261QF0400X | OD00003794 | WA | Yes |
Addresses
Primary practice location
1515 E Columbia St
Othello, WA 99344-1846
Mailing address
1515 E. Columbia St.
Othello, WA 99344
Phone (509) 488-5256
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 8908941 | Other | WA | CRIME VICTIMS # |
| 2029130 | Medicaid | WA | |
| 0035900 | Other | WA | DEPT L&I # |
| 7107675 | Other | WA | UGS MDC DSHS CROSSOVER |
Other names
- Columbia Basin Health Association
Other providers in Othello, WA
- Columbia Basin Health Association
- Columbia Basin Health Association
- Columbia Basin Health Association
- Columbia Basin Health Association
- Columbia Basin Health Association
- Annie M Coronado
- County of Adams
- County of Adams
- County of Adams
- Brent Darrington
All providers in Othello, 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 6, 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.