2011-08-12T12:14:44-05:00 2010-12-31 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2010-01-01 330844408 LITTLE COMPANY OF MARY ANCILLARY SERVICES CORPORATION LITT 8188473015 4101 TORRANCE BLVD TORRANCE CA 90503 Michael L Butler 4255253985 2011-08-12 1 Sara Elizabeth J Hyre CPA 4254544919 2010 2016-02-24 21:20:13Z Elizabeth Zuanich 4101 TORRANCE BLVD TORRANCE CA 90503 6352356 0 X http://www2.providence.org/torrance/services/ X 1999 CA Outpatient Diagnostic Imaging Services. 14 14 0 0 0 0 0 0 6035929 6163162 3477 1150 217974 188044 6257380 6352356 0 0 0 0 2038548 2044898 0 0 0 3338342 2846306 5376890 4891204 880490 1461152 12528469 17104966 3496511 6629098 9031958 10475868 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Outpatient Diagnostic Imaging Services. 0 0 3215206 0 6166387 LCMASC provides imaging services on an outpatient basis. Imaging services include bone density testing, mammograms, CT scans, MRI scans, and ultrasounds.Providence Health System - Southern California, a non-profit public benefit corporation, is organized and operated exclusively for charitable purposes and, through its division Little Company of Mary Health Services (LCMHS) is the sole member of Little Company of Mary Ancillary Services Corporation (LCMASC). LCMHS has a mission statement dedicated to providing care to the people living within its service area. The Mission Statement is:"The mission of Little Company of Mary Health Services and its affiliates is a part of the larger mission of the Sisters of Little Company of Mary to make visible the healing presence of Jesus. Our mission embraces the care of the sick and dying through the Catholic health ministry and meeting the health needs of our community."The significance of this mission can be expressed as commitments to respect for the individual, quality of care, education for professionals and the community, and outreach to those in need. LCMASC will not turn away a patient because of inability to pay.LCMASC provides outpatient diagnostic imaging services and participates in the following charitable services, community benefit programs, community education programs and outreach programs:Mary Potter Program for Human Dignity - LCMASC provides charity care for those persons in need of financial assistance. Persons who are unable to pay for services receive their imaging/healthcare services for either no cost or at a reduced cost. Referrals for charitable services are received from referring physicians, from the radiologists, from the patients themselves, from the hospitals, etc.Cancer Education Programs - LCMASC and LCMHS provide numerous cancer education awareness, prevention and screening programs. These programs cover breast cancer, colon cancer, skin cancer, prostate cancer, lung cancer, brain cancer, etc. The programs address a better understanding and awareness of cancer, early detection, screening, diet, self-examinations, as well as other topics.Cancer Research - LCMASC participates with the Western Clinical Research lab to assist with the UCLA cancer research program. Bone scans, chest x-rays, CT scans and MRIs on cancer patients are performed at reduced costs.Tumor Registry - LCMASC, together with Little Company of Mary Hospital (LCMH) maintains a tumor registry program. All patients with cancer diagnosis are registered for long-term follow-up.Resource Library - LCMASC, together with LCMH, maintains a resource library where patients may obtain a great variety of information on specific cancer issues.As an affiliate of Providence Health & Services, LCMASC adheres to the System's policy of providing care to all persons who are ill regardless of their ability to pay. LCMASC also has a policy of providing community services through a variety of health related programs. Total outpatient visits for the year 2010 were 34,824. 3215206 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 X 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 CA X LCM Accounting Department 8188473015 4101 Torrance Blvd Torrance CA 90503 X Lucille Dean SP 11.80 X X 0 0 0 M Adrian Davis LCM 3.20 X 0 0 0 Mary Corita Heid RSM 3.80 X 0 0 0 Michael A Stein 4.70 X 0 18000 0 Michael Holcomb 3.70 X 0 15000 0 Dana A Rasmussen 3.40 X 0 15000 0 Paul A Redmond 3.00 X 0 18000 0 James S Roberts MD 6.00 X 0 15000 0 Peter J Snow 4.10 X 0 15000 0 Jeffrey B Clode MD 5.40 X 0 18000 0 Sallye Liner 3.50 X 0 3750 0 Owen B Robinson 5.50 X 0 15000 0 Cheryl M Scott 3.00 X 0 15000 0 Ellen L Wolf 6.80 X 0 15000 0 John F Koster MD 50.00 X 0 2346502 794703 Michael L Butler 65.00 X 0 1038275 340314 Jeffrey W Rogers 50.00 X 0 1259397 465326 Eugene Al Parrish 50.00 X 0 1047158 332492 John V Fletcher 60.00 X 0 1277503 584795 Janice J Jones 55.00 X 0 1140032 349285 Gregory Van Pelt 60.00 X 0 2314095 484343 Russell Danielson 50.00 X 0 4449992 397656 Arnold R Schaffer 60.00 X 0 1980618 371481 John O Mudd 55.00 X 0 856420 395919 Keith Marton MD 60.00 X 0 717815 215947 Claudia Haglund 50.00 X 0 501163 126574 Joel S Gilbertson 50.00 X 0 454656 56288 Cindra R Syverson 55.00 X 0 485868 108238 John Kenagy 60.00 X 0 447695 141020 Orest Holubec 50.00 X 0 335415 22577 Deborah Burton 60.00 X 0 341476 168307 Myron Berdischewsky MD 60.00 X 0 609142 268959 David Brown 55.00 X 0 342030 110948 Gary Flaming 55.00 X 0 314477 76918 Michael Hunn 60.00 X 0 490880 166313 Dave Hunter 55.00 X 0 296582 148481 Tricia Roscoe 55.00 X 0 290201 73002 Richard J Umbdenstock 0.00 X 0 32220 0 Michael J Madden 0.00 X 0 359717 0 Charles E Hawley 0.00 X 0 2137748 17773 Thomas Johnson 0.00 X 0 325409 91452 0 26355236 6309111 0 1 1 0 Advanced Imaging of South Bay 21143 Hawthorne Blvd 327 Torrance CA 90503 Diagnostic Imaging Service 1837078 GE Healthcare 101 Carnegie Center Princeton NJ 085406231 Equip Repair/Maintenance 107283 Varian Medical Systems Inc 3100 Hansen Way M/S E-047 Palo Alto CA 943041038 Equip Repair/Maintenance 101184 3 Primary Care 621500 6163162 6163162 6163162 1150 1150 53191 53191 53191 53191 Cost Recoveries 900099 131628 131628 Medical Records 900099 3225 3225 134853 6352356 6166387 0 185969 1903612 1448262 455350 1000 475 525 140286 109883 30403 6615 6615 412286 212776 199510 388965 347576 41389 2110 1653 457 204781 118437 86344 1056461 305032 751429 726467 636498 89969 Bad Debts 23418 22778 640 Licensing Expense 15553 11836 3717 Bank & Credit Cards Fee 8108 8108 Medicare Late Claim 804 804 Petty Cash 327 327 411 411 4891204 3215206 1675998 0 44760 281 213555 465505 22500 23158 11605 9439 18380473 12902728 6181256 5477745 6054793 11128838 12528469 17104966 312278 305747 3184233 6323351 3496511 6629098 X 9031958 10475868 9031958 10475868 12528469 17104966 X 1461152 -17242 X X 0 1 1 X 0 X 5217706 5146776 5903907 6039494 6166387 28474270 146798 127724 145891 161219 131628 713260 5364504 5274500 6049798 6200713 6298015 29187530 0 0 0 29187530 45470 57610 52211 56668 54341 266300 45470 57610 52211 56668 54341 266300 5409974 5332110 6102009 6257381 6352356 29453830 0.99100 0.99240 0.00900 0.00760 X 1390000 1390000 5474552 2621634 2852918 500240 403928 96312 11015681 9877166 1138515 5477745 Due from Affiliates 11102371 AR Other - Rent Receivable 26467 11128838 Due to Affiliates 6323351 6323351 Description of Uncertain Tax Positions Under FIN 48: Part X: The Health System recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. X X X X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 John F Koster MD 0 1073328 0 1236674 0 36500 0 777729 0 16974 0 3141205 0 0 Michael L Butler 0 734748 0 283527 0 20000 0 317186 0 23128 0 1378589 0 0 Jeffrey W Rogers 0 418582 0 825815 0 15000 0 446566 0 18760 0 1724723 0 0 Eugene Al Parrish 0 491513 0 535611 0 20034 0 310289 0 22203 0 1379650 0 0 John V Fletcher 0 516196 0 708989 0 52318 0 564812 0 19983 0 1862298 0 0 Janice J Jones 0 552837 0 534946 0 52249 0 326291 0 22994 0 1489317 0 0 Gregory Van Pelt 0 678198 0 1545235 0 90662 0 463313 0 21030 0 2798438 0 0 Russell Danielson 0 511864 0 3879403 0 58725 0 373761 0 23895 0 4847648 0 0 Arnold R Schaffer 0 609272 0 1144945 0 226401 0 349661 0 21820 0 2352099 0 0 John O Mudd 0 325749 0 494171 0 36500 0 381188 0 14731 0 1252339 0 0 Keith Marton MD 0 211843 0 237842 0 268130 0 198251 0 17696 0 933762 0 0 Claudia Haglund 0 314668 0 142918 0 43577 0 109252 0 17322 0 627737 0 0 Joel S Gilbertson 0 311580 0 97519 0 45557 0 38285 0 18003 0 510944 0 0 Cindra R Syverson 0 365566 0 105302 0 15000 0 87877 0 20361 0 594106 0 0 John Kenagy 0 324910 0 91285 0 31500 0 122409 0 18611 0 588715 0 0 Orest Holubec 0 128753 0 75000 0 131662 0 13893 0 8684 0 357992 0 0 Deborah Burton 0 252225 0 61612 0 27639 0 153009 0 15298 0 509783 0 0 Myron Berdischewsky MD 0 369222 0 182574 0 57346 0 245165 0 23794 0 878101 0 0 David Brown 0 250803 0 76227 0 15000 0 93721 0 17227 0 452978 0 0 Gary Flaming 0 212910 0 70067 0 31500 0 61683 0 15235 0 391395 0 0 Michael Hunn 0 363490 0 111813 0 15577 0 153028 0 13285 0 657193 0 0 Dave Hunter 0 242116 0 37206 0 17260 0 132818 0 15663 0 445063 0 0 Tricia Roscoe 0 234081 0 41120 0 15000 0 59788 0 13214 0 363203 0 0 Richard J Umbdenstock 0 0 0 32220 0 0 0 0 0 0 0 32220 0 0 Michael J Madden 0 0 0 343217 0 16500 0 0 0 0 0 359717 0 0 Charles E Hawley 0 25690 0 2048448 0 63610 0 17773 0 0 0 2155521 0 0 Thomas Johnson 0 8513 0 62573 0 254323 0 85036 0 6416 0 416861 0 0 Part I, Line 1a The Providence Expense Reimbursement Procedures include the following policies: First Class Travel or Charter Travel or Travel of Companions Air travel is reimbursable for tourist or economy class and should be at the least expensive airfare; which permits departures and arrivals at reasonable times and reasonable distance traveled. Employees are encouraged to plan in advance to get available discounts. Airline frequent flyer upgrades will never be reimbursed. First class air travel will only be reimbursed when tourist or economy class air travel is not available and business travel is mandated by a supervisor. In the rare circumstance that an executive must fly on a first class full fare ticket, their senior level supervisor must approve this expense. Companion travel will only be reimbursed by the organization for travel related to relocation, and should not exceed two relocation-related visits, unless approval by the VP, Chief Human Resources Officer. During 2010, a total of four first-class tickets were purchased. Tax Indemnifications or Gross-Up Payments Providence Health & Services follows the federal and state taxation laws related to relocation expenses paid to the employee or to a third party on the employee's behalf. They are considered income and are therefore subject to payroll taxes. Based on the way Providence has chosen to pay the relocation expenses, Providence reports reimbursements and payments to vendors as income and these expense payments are reflected on the executive's Form W-2. Providence will gross-up the relocation benefits to offset the personal tax burden to the employee for IRS allowable expenses. During 2010, the following Key Employees received gross-up payments: Russell Danielson Joel Gilbertson Orest Holubec Eugene "Al" Parrish Arnold R. Schaffer Myron Berdischewsky The amounts reported for these gross-up payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Discretionary Spending Account Providence Health & Services provides an executive flex spending allowance per year (paid bi-weekly). This benefit is provided as discretionary spending because the organization does not reimburse for or provide additional executive benefits, such as a car allowance, additional executive life or disability insurance, or other market-based executive benefits practices. Housing Allowance or Residence for Personal Use Providence Health & Services provides housing allowances for purposes of relocation assistance only. Providence may pay temporary living expenses for the employee up to a maximum of 90 calendar days. Covered expenses are rent (excluding "rent" which may be paid in order to occupy a new permanent residence until the title clears) and utilities, including heat, electricity, gas, water, local internet and local telephone and garbage services. The vice president/chief human resources officer may approve temporary housing assistance for up to six months when family relocation is delayed to accommodate the school year or equivalent circumstances. Only in extenuating circumstances is housing extended beyond this six month period. During 2010, the following Key Employees received relocation payments: Joel Gilbertson Orest Holubec Arnold R. Schaffer Myron Berdischewsky The amounts reported for these relocation payments are included on Schedule J, Part II, Column B (iii) - Other Reportable Compensation. Part I, Lines 4a-b A) DBSERP = Defined Benefit Supplemental Executive Retirement Plan B) DCSERP = Defined Contribution Supplemental Executive Retirement Plan C) DBCBRP = Defined Benefit Cash Balance Restoration Plan D) ESP = Elective Survivor Plan E) SOP = Share Option Plan 1) John F. Koster, MD a) Taxable DBSERP Vested but not Paid - $736,499 b) DCSERP Earned - $756,501 2) Michael L. Butler a) DBSERP Earned but not Vested - $1,296 b) DCSERP Earned - $292,794 3) Jeffrey W. Rogers a) Taxable DBSERP Vested but not Paid - $697,854 b) Non-Taxable DBSERP Vested but not Paid - $ 283,728 c) DCSERP Earned - $44,923 d) ESP Interest Credit - $73,103 4) Russell Danielson a) Taxable DBSERP Paid - $ 3,315,890 b) Non-Taxable DBSERP Vested but not Paid - $74,603 c) DCSERP Earned - $217,379 d) ESP Interest Credit - $69,081 5) Gregory Van Pelt a) Taxable DBSERP Vested but not Paid - $ 1,308,937 b) Non-Taxable DBSERP Vested but not Paid - $248,979 c) DCSERP Earned - $89,556 d) ESP Interest Credit - $80,697 e) SOP Paid - $54,162 6) Arnold R. Schaffer a) Taxable DBSERP Vested but not Paid - $873,172 b) DCSERP Earned - $333,896 7) John V. Fletcher a) Taxable DBSERP Vested but not Paid - $ 484,554 b) Non-Taxable DBSERP Vested but not Paid - $20,519 c) DCSERP Earned - $474,635 d) ESP Interest Credit - $42,239 e) SOP Paid - $15,818 8) Janice J. Jones a) Taxable DBSERP Vested but not Paid - $ 299,823 b) Taxable DBCBRP Vested but not Paid - $ 64 c) DCSERP Earned - $303,348 c) SOP Paid - $15,749 9) Eugene "Al" Parrish a) Taxable DBSERP Vested but not Paid - $288,259 b) DCSERP Earned - $295,970 10) John O. Mudd a) Taxable DBSERP Vested but not Paid - $362,132 b) DCSERP Earned - $372,693 11) Keith Marton, MD a) DBSERP Earned but not Vested - $180 b) DCSERP Earned - $193,810 12) Myron Berdischewsky, MD a) DCSERP Earned - $222,924 13) Claudia Haglund a) Taxable DBSERP Vested but not Paid - $41,847 b) DCSERP Earned - $43,139 c) ESP Interest Credit - $20,878 d) SOP Paid - $ 14,583 14) Michael Hunn a) DBSERP Earned but not Vested - $324 b) DCSERP Earned - $141,373 15) Cindra R. Syverson a) DCSERP Earned - $78,225 16) Joel S. Gilbertson a) DCSERP Earned - $25,015 17) John Kenagy a) DBSERP Earned but not Vested - $324 b) DCSERP Earned - $108,023 18) David S. Brown a) DCSERP Earned - $70,731 19) Deborah Burton a) DBSERP Earned but not Vested - $300 b) DCSERP Earned - $135,764 20) Orest Holubec a) DCSERP Earned - $6,543 21) Gary K. Flaming a) DCSERP Earned - $15,811 22) David H. Hunter a) DBCBRP Earned but not Paid - $203 b) DCSERP Earned - $110,680 23) Patricia A. Roscoe a) DCSERP Earned - $38,038 24) Charles E. Hawley a) Taxable DBSERP Paid - $ 1,947,717 b) DCSERP Earned - $12,926 c) SOP Paid - $ 28,456 25) Michael J. Madden a) Taxable DBSERP Paid - $ 343,217 26) Thomas Johnson a) DCSERP Earned - $82,979 27) Richard J. Umbdenstock a) DBSERP Paid - $ 32,220 Part I, Lines 4a-b SEVERANCE 1)Keith Marton, MD - $201,412 2)Thomas Johnson - $223,731 Supplemental Information Part III FORM 990, SCHEDULE J, PART II - EXECUTIVE PERFORMANCE AWARDS PROGRAM The Providence Executive Performance Awards Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). The performance award is based on the level of accomplishment of annual system objectives and personal objectives. In 2010, 50 percent of the participant awards were based on pre-determined organizational goals consistent with Providence's five strategic priorities of: mission driven, financially responsible, people centered, service oriented and quality focused. In 2010 the percent allocation for each of these strategic priorities was: Mission driven 10% Financially responsible 10% People centered 10% Service oriented 10% Quality focused 10%. To ensure affordability of the program, the organization (system, region or entity) must meet a threshold of 50 percent of budgeted net operating income. Form 990, Part VI, Section A, line 6 Providence Health System - Southern California is the Corporate Member. Form 990, Part VI, Section A, line 7a The Corporate Member has the power to: 1) Fix the number of Directors and appoint the Board of Directors 2) Remove, with or without cause, any member of the Board of Directors 3) Appoint the Chair of the Board of Directors Form 990, Part VI, Section A, line 7b Reserved Powers of the Corporate Member: 1) Approve the mission and philosophy 2) Adopt, amend or repeal the Articles of Incorporation or Bylaws 3) Remove, with or without cause, the Chair of the Board 4) Approve the annual budget and long-term capital and operational budgets and any changes exceeding 10% of the original budget 5) Approve the acquisition of assets, the incurrence of indebtedness or the lease, sale, transfer, assignment or encumbering of assets exceeding $50,000. 6) Approve an agreement to affiliate, merge, restructure, liquidate or dissolve this Corporation 7) Approve the Long-Range Consolidated Strategic and Financial Integrated Plan 8) Approve the selection of the independent accountant as defined in Section 5013 of the California Corporations Code 9) Organize or acquire any subsidiary nonprofit or for-profit corporations and any health care joint ventures 10) Accept a legacy or gift that imposes a permanent or continuing obligation Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by the internal Director of Taxes and external tax advisors. The Board of Directors reviewed the Form 990 prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Providence Health & Services maintains a conflict of interest policy that applies to board members and management of all Providence-related organizations. The purpose of the policy is to guide and direct those serving the Providence Health & Services' corporations and other legal entities so they can (1) fulfill their fiduciary responsibilities and exercise stewardship in ways that promote and protect the best interests of Providence and, (2) avoid situations that create a conflict, or the appearance of a conflict, between the interests of an individual associated with Providence and Providence. On an annual basis, each board member and management level employee must complete and submit an updated conflict of interest statement. Conflict of interest disclosures are reviewed by the System Integrity Department working in conjunction with the Department of Legal Affairs. If it is determined that an actual conflict exists, appropriate follow-up action is taken with the individual to rectify the conflict. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence Boards Human Resources Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Each year, the Board Chair conducts a formal performance evaluation of the President/CEO that considers input from the other directors and senior leaders reporting to the President. The evaluation is discussed with the Human Resources Committee and then a recommendation is made by the committee to the full Board. The Board Chair and the Chair of the Human Resources Committee also meet with an independent consultant to develop a salary recommendation; which is reviewed and approved first by the committee and then by the Board of Directors. Additionally, the President/CEO utilizes the market information provided by the consultant along with formal performance evaluations, to determine salary recommendations for other senior executives. This process includes a rigorous analysis of those recommendations with the Human Resources Committee as a part of the review and approval process. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The consolidated financial statements are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Interaffiliate Net Asset Transfer -17,242. Total to Form 990, Part XI, Line 5: -17,242. HOURS WORKED FORM 990, PART VII, LINE 1A The average hours per week reflect hours worked for the entire Providence Health & Services healthcare system and are not allocated to the individual reporting entity. RELIGIOUS COMMUNITY MEMBERS FORM 990, PART VII As members of the Religious Community, each Sister has taken a vow of poverty as a compulsory part of her religious life. Any compensation for services of a Sister inures only for the benefit of the Community, not the individual members. All payments for services are made directly to the Religious Community. EMPLOYEE COMPENSATION FORM 990, PART I, LINE 5 & PART V, LINE 2A The employees working at LCMASC are paid by Providence Health System - Southern California EIN# 51-0216589. Therefore, no W-2s are issued by the reporting organization. ADDRESS INFORMATION FORM 990, PART VI, LINE 9 All Officers, Directors and Key Employees of the reporting organization can be reached at: 1801 Lind Ave SW, #9016, Renton, WA. 98057-9016. Providence Health & Services - Washington 1801 Lind Avenue SW 9016 Renton WA 980579016 510216586 Healthcare System WA 501( c)(3) Line 3 Providence Health & Services 0 Providence Health & Services - Oregon 1801 Lind Avenue SW 9016 Renton WA 980579016 510216587 Healthcare System OR 501( c)(3) Line 3 Providence Health & Services 0 Providence Health System - So California 1801 Lind Avenue SW 9016 Renton WA 980579016 510216589 Healthcare System CA 501( c)(3) Line 3 Providence Health & Services 0 Everett Transitional Care Services PO Box 1067 Everett WA 982061067 943264605 Transitional Care WA 501( c)(3) Line 9 N/A 0 Providence Oregon Management Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 930813977 Shell Corporation OR 501( c)(3) Line 1 PH & S - Oregon 0 Providence Plan Partners 3601 SW Murray Blvd 10 Beaverton OR 97005 911861964 Healthcare Services OR 501( c)(4) N/A PH & S - Oregon 0 Providence Health Plan 3601 SW Murray Blvd 10 Beaverton OR 97005 930863097 Health Service Contractor OR 501( c)(4) N/A Providence Plan Partners 0 Providence Health Assurance 3601 SW Murray Blvd 10 Beaverton OR 97005 550828701 Medicaid Healthcare Provider OR 501( c)(4) N/A Providence Health Plan 0 Providence Medical Institute 4101 Torrance Blvd Torrance CA 90503 330283773 Healthcare CA 501( c)(3) Line 11/Type I PHS - So California 0 Providence TrinityCare Hospice 2601 Airport Drive 230 Torrance CA 90505 953264139 Hospice CA 501( c)(3) Line 9 PHS - So California 0 Providence Health System Housing 1801 Lind Avenue SW 9016 Renton WA 980579016 943230587 Assisted Living AK 501( c)(3) Line 9 PH & S - Washington 0 Providence Blanchet Association 1700 Providence Pl Centralia WA 98531 911789266 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 St Luke Association 350 Washington Ave SE Chehalis WA 98352 943176618 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Rossi Association 1700 Providence Pl Centralia WA 98531 311584166 Housing WA 501( c)(3) Line 9 PH & S - Washington 0 Lundberg Association 5921 E Burnside Portland OR 97215 911562797 Housing OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Francis Association 3415 12th Avenue NE Olympia WA 98506 943244854 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Peter Claver Association 7101 38th Avenue South Seattle WA 98118 311629656 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence St Elizabeth House Association 3201 SW Graham St Seattle WA 98126 912171539 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Gamelin House Association 4515 MLK Jr Way S Ste 200 Seattle WA 98108 311744654 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 The Gamelin Association 312 North Fourth St Yakima WA 98901 911180824 Housing WA 501( c)(3) Line 1 PH & S - Washington 0 The Gamelin Oregon Association 5520 NE Glisan Portland OR 97213 911214491 Housing OR 501( c)(3) Line 9 PH & S - Oregon 0 The Gamelin California Association 540 23rd St Oakland CA 94612 911293869 Housing CA 501( c)(3) Line 9 PHS - So California 0 Gamelin Washington Association 1423 First Avenue Seattle WA 98101 201910170 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Foundation 1801 Lind Avenue SW 9016 Renton WA 980579016 943078543 Support PH&S Institutions WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Alaska Foundation 3300 Providence Drive - B Tower2 Anchorage AK 99508 920093565 Support PHS-Alaska AK 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence St Peter Foundation 413 Lilly Road NE Olympia WA 985065166 911097056 Support Affiliated Tax-Exempt Organization WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Health Care Foundation (Centralia) 914 S Scheuber Road Centralia WA 98531 911433382 Support Providence Centralia Hospital WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Mount St Vincent Foundation 4831 - 35th Avenue SW Seattle WA 981262799 911188119 Support Providence Mount St.Vincent WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Marianwood Foundation 3725 Providence Point Drive SE Issaquah WA 980297219 931554288 Support Providence Marianwood WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Newberg Health Foundation 1001 Providence Drive Newberg OR 97132 930889144 Support Providence Newberg Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Seaside Hospital Foundation 725 S Wahanna Rd Seaside OR 97138 930927320 Support Providence Seaside Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Community Health Foundation 1111 Crater Lake Ave Medford OR 97504 930692907 Support Providence Medford Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Benedictine Nursing Center Foundation 540 South Main St Mt Angel OR 973629532 911940286 Support Providence Benedictine Nursing Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Portland Medical Foundation 4805 NE Glisan St Portland OR 972132967 931231494 Support Providence Portland Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence St Vincent Medical Foundation 9205 SW Barnes Rd Portland OR 97225 930575982 Support Providence St. Vincent Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Milwaukie Foundation 10150 SE 32nd Milwaukie OR 97222 943079515 Support Providence Milwaukie Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Child Center Foundation 830 NE 47th Portland OR 97213 930800140 Support Providence Child Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence TrinityCare Hospice Foundation 2601 Airport Drive 230 Torrance CA 90505 330261016 Support TrinityCare Hospice CA 501( c)(3) Line 7 PHS - 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Montana MT 501( c)(3) Line 7 PH & S - Washington 0 University of Great Falls 1301 20th Street South Great Falls MT 59405 810231777 Post Secondary Education MT 501( c)(3) Line 2 PH & S - Washington 0 E WA & MT Unemployment Compensation Insurance Trust 1801 Lind Avenue SW 9016 Renton WA 980579016 911082119 Unemployment Benefits WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Willamette Falls Medical Foundation 1500 Division Street Oregon City OR 97045 931003750 Support Willamette Falls Hospital OR 501( c)(3) Line 11/Type I PH & S - Oregon 0 Willamette Falls Hospital dba Providence Willamette Falls Medical Center 1500 Division Street Oregon City OR 97045 930426018 Healthcare OR 501(c )(3) Line 3 PH & S - Oregon 0 Providence Hood River Memorial Hospital Foundation Inc 811 13th St Hood River OR 97031 930921990 Support Providence Hood River Memorial Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Hospice and Home Care Foundation 2731 Wetmore Avenue Suite 500 Everett WA 98201 272552749 Support Program & Activities of PHHC WA 501(c )(3) Line 7 PH & S - Washington 0 Providence Imaging Center 3340 Providence Drive Anchorage AK 99508 920118807 Medical Imaging AK N/A Providence Surgery Centers LLC PO Box 233889 Anchorage AK 99523 203567411 Surgery AK N/A Mountainstar Clinical Laboratories LLC 611 N Perry Spokane WA 99202 261345983 Outpatient Lab MT N/A Broadway Imaging LLC 500 W Broadway Missoula MT 59802 522405971 Medical Imaging MT N/A Providence Surgery Center LLC 902 N Orange Street Missoula MT 59802 841401625 Outpatient Surgery MT N/A Center for Medical Imaging-Tanasbourne LLC 1235 NE 47th Ave 288 Portland OR 97213 200477972 Imaging - Diagnostics OR N/A Center for Medical Imaging-Bridgeport LLC 1235 NE 47th Ave 288 Portland OR 97213 260796953 Imaging - Diagnostics OR N/A Center for Specialty Surgery LLC 11782 SW Barnes Rd Portland OR 97225 263638838 Ambulatory Surgery Center OR N/A Clackamas Radiation Oncology Center LLC 1235 NE 47th Ave 288 Portland OR 97213 260381897 Radiation Oncology OR N/A Oregon Outpatient Surgery Center 7300 SW Childs Rd Tigard OR 97224 223883387 Ambulatory Surgery Center OR N/A Surgery Center at Tanasbourne LLC 1235 NE 47th Ave 260 Portland OR 97213 208187971 Ambulatory Surgery Center OR N/A ProvidenceSilverton Rehab LLC 1235 NE 47th Ave 260 Portland OR 97213 481287267 Rehab Services OR N/A Portland Medical Imaging LLC 10538 SE Washington St Portland OR 97216 201054971 Imaging - Diagnostics OR N/A Providence Radiation Oncology Development Assn LLC 1235 NE 47th Ave 288 Portland OR 97213 260682491 Real Estate - MOB OR N/A Central Point MRI LLC 870 S Front St Central Point OR 97502 261975164 MRI Services OR N/A Greater Valley Medical Building LP 501 S Buena Vista St Burbank CA 91505 954570858 Real Estate - MOB CA N/A Pathology Associates Medical Laboratories LLC 611 N Perry Spokane WA 99202 270943279 Outpatient Lab WA N/A Southern Idaho Regional Laboratory LLC 611 N Perry Spokane WA 99202 820511819 Outpatient Lab ID N/A Tri-Cities Laboratory LLC 611 N Perry Spokane WA 99202 911773986 Outpatient Lab WA N/A Alpha Medical Laboratory LLC 611 N Perry Spokane WA 99202 912017347 Outpatient Lab ID N/A PacLab LLC 611 N Perry Spokane WA 99202 911743952 Outpatient Lab WA N/A HealthServicesNW LLC PO Box 389672 Seattle WA 98138 311750915 Medical Billing WA N/A Medalia Healthcare LLC 1801 Lind Ave SW 9016 Renton WA 98057 911660459 Physician Benefits WA N/A Distribution Operations Center LLC 1801 Lind Ave SW 9016 Renton WA 98057 271054858 Supplies Purchasing Agent WA N/A Oregon Advanced Imaging LLC 881 OHare Parkway Medford OR 97504 450471748 Medical Imaging OR N/A ProvidenceUSP Surgery Centers LLC 11550 Indian Hills Road 160 Mission Hills CA 91345 200905938 Ambulatory Surgery Center CA N/A California Laboratory Associates LLC 501 Buena Vista Burbank CA 91505 273888692 Outpatient Lab CA N/A Providence Health Ventures Inc 4101 Torrance Blvd Torrance CA 90503 330122216 Investment CA N/A C Caron Health Corporation 510 West Front Street Missoula MT 59802 810486082 Medical Physician Service MT N/A C Providence Health Care Ventures Inc 101 West 8th Ave TAF C-9 Spokane WA 99204 900155714 Clinical/Medical Lab WA N/A C Providence Physician Services Co 101 West 8th Ave TAF C-9 Spokane WA 99208 911216033 Clinical/Medical Lab WA N/A C Yakima Medical Arts Inc 611 N Perry Suite 100 Spokane WA 99202 910787963 Rental Real Estate WA N/A C Bourget Health Services Inc PO Box 2687 Spokane WA 99202 911354431 Clinical/Medical Lab WA N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0