NPIMap

Organization Active NPI

Northeast Community Clinic

  • Federally Qualified Health Center (FQHC)
  • Harbor City, CA
National Provider Identifier
1043725583
Registry record updated Oct 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST COMMUNITY CLINIC
Practice address
1403 Lomita Blvd Ste 103
Harbor City, CA 90710-2084
Phone
(310) 784-1800
Fax
(310) 602-3737
NPI assigned
Dec 6, 2017
Last updated
Oct 15, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTHEAST COMMUNITY CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 15, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Christopher Tak Lau, MDNPI 1548365968
Title
Executive Director
Phone
(626) 457-6900

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1403 Lomita Blvd Ste 103
Harbor City, CA 90710-2084

Mailing address

2550 W Main St Ste 301
Alhambra, CA 91801-7003
Phone (626) 457-6900

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040417000619 CA Part B Supplier - Clinic/Group Practice 5193710275 Receives reassigned benefits from 65 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bell, CA; Harbor City, CA; Hawthorne, CA; Huntington Park, CA; Los Angeles, CA; Wilmington, CA
O20180124000324 CA Part A Provider - Federally Qualified Health Center (FQHC) 5193710275 Practice locations: Harbor City, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043725583. Details of each certification follow.

Federally qualified health center certification: CCN 921034

Legal name
NORTHEAST COMMUNITY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 29, 2017
Last certification
Dec 29, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 27, 1971 in CA
Enrollment address
1403 Lomita Blvd
Ste 103
Harbor City, CA 90710-2084

Other NPIs with the same Medicare PAC ID 13

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 13

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Northeast Community Clinic

Locations

1403 Lomita Blvd
Ste 103
Harbor City, CA 90710
Phone (310) 784-1800

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Octavio Fierros Individual Corporate DirectorBoard Member Mar 10, 2021
Fumio Robert Nakahiro Individual Corporate DirectorBoard Member May 16, 1999
Irene Huerta Individual Corporate DirectorBoard Vice Chair Mar 21, 2018
Ali Mohammad Tweini Individual Corporate DirectorBoard Member Aug 11, 2021
Christopher T Lau Individual Corporate OfficerExecutive Director Feb 1, 2003
Corporate DirectorExecutive Director Feb 1, 2003
W-2 Managing EmployeeExecutive Director Feb 1, 2003
Ruby Y Medrano Individual Corporate DirectorBoard Member Jan 12, 2006
Mark Gonzalez Individual Corporate DirectorBoard Chair Mar 11, 2010
Dalia M Jaramillo Individual Corporate DirectorBoard Treasurer Jul 6, 2006
Monica Guardian Individual Corporate DirectorBoard Secretary Jan 1, 2015
Bernardo J Carrillo Individual Corporate OfficerOperations Director Jun 1, 2020
W-2 Managing EmployeeOperations Director Jun 1, 2020
Katrina Manning Individual Corporate DirectorBoard Member Mar 9, 2017

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1512518400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634256000000",
    "number": "1043725583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2550 W MAIN ST STE 301",
            "city": "ALHAMBRA",
            "state": "CA",
            "postal_code": "918017003",
            "telephone_number": "626-457-6900",
            "fax_number": "626-457-5022"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1403 LOMITA BLVD STE 103",
            "city": "HARBOR CITY",
            "state": "CA",
            "postal_code": "907102084",
            "telephone_number": "310-784-1800",
            "fax_number": "310-602-3737"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST COMMUNITY CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTHEAST COMMUNITY CLINIC",
        "enumeration_date": "2017-12-06",
        "last_updated": "2021-10-15",
        "certification_date": "2021-10-15",
        "status": "A",
        "authorized_official_last_name": "LAU",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "TAK",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "626-457-6900",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Harbor City, CA

Sources for this page

Verify at the official NPI Registry.