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CLEARWATER MEDICAL CENTER, P.L.L.C.

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Company Details

Name: CLEARWATER MEDICAL CENTER, P.L.L.C.
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 17 Jan 1995 (31 years ago)
Financial Date End: 31 Jan 2020
Date dissolved: 08 Apr 2020
Entity Number: 5300
Place of Formation: IDAHO
File Number: 5300
ZIP code: 83501
County: Nez Perce County
Principal Address: 1522 17TH ST LEWISTON, ID 83501
Mailing Address: JILL BALL 1522 17TH ST LEWISTON, ID 83501-3652

Agent

Name Role Address
CELSO R CHAVEZ Agent 1522 17TH ST, LEWISTON, ID 83501

Unique Entity ID

CAGE Code:
7L7N1
UEI Expiration Date:
2019-02-09

Business Information

Doing Business As:
CLEARWATER MEDICAL CLINIC
Activation Date:
2018-02-09
Initial Registration Date:
2016-03-23

Commercial and government entity program

CAGE number:
7L7N1
Status:
Obsolete
Type:
Non-Manufacturer
CAGE Update Date:
2023-02-11
CAGE Expiration:
2023-02-10

Contact Information

POC:
JILL BALL

National Provider Identifier

NPI Number:
1558452268

Authorized Person:

Name:
DR. CELSO R CHAVEZ
Role:
OWNER PHYSICIAN
Phone:

Taxonomy:

Selected Taxonomy:
207Q00000X - Family Medicine Physician
Is Primary:
No
Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
No
Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
No
Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
No
Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
No

Contacts:

Fax:
2087434642

Form 5500 Series

Employer Identification Number (EIN):
820394208
Plan Year:
2019
Number Of Participants:
13
Sponsors Telephone Number:
Plan Year:
2018
Number Of Participants:
46
Sponsors Telephone Number:
Plan Year:
2017
Number Of Participants:
46
Sponsors Telephone Number:
Plan Year:
2016
Number Of Participants:
42
Sponsors Telephone Number:
Plan Year:
2015
Number Of Participants:
38
Sponsors Telephone Number:

Filing

Filing Name Filing Number Filing date
Dissolution/Revocation - Administrative 0003837826 2020-04-08
Annual Report 0003390858 2019-01-09
Annual Report 0000957358 2018-01-04
Annual Report 0000957356 2017-01-05
Legacy Amendment 0000957354 2016-04-06

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Date of last update: 13 Jul 2025

Sources: Idaho Secretary of State