NPIMap

Organization Active NPI

El Dorado County Community Health Center

Doing business as El Dorado Community Health Center Cameron Park Main

  • Federally Qualified Health Center (FQHC)
  • Cameron Park, CA
National Provider Identifier
1073981783
Registry record updated Nov 21, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EL DORADO COUNTY COMMUNITY HEALTH CENTER
Doing business as
El Dorado Community Health Center Cameron Park Main
Practice address
3100 Ponte Morino Dr
Suite 120
Cameron Park, CA 95682-7432
Phone
(530) 621-7700
NPI assigned
Sep 11, 2015
Last updated
Nov 21, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
EL DORADO COUNTY COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 21, 2023

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

Authorized official

Name
Judy Stein, CFO
Title
Cfo
Phone
(530) 748-2327

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X CA Primary
Case Manager/Care Coordinator 171M00000X

Addresses

Primary practice location

3100 Ponte Morino Dr
Suite 120
Cameron Park, CA 95682-7432

Mailing address

4212 Missouri Flat Rd
Placerville, CA 95667-6269
Phone (530) 621-7700

Other names 1

  • El Dorado Community Health Center Cameron Park Main Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160330002670 CA Part A Provider - Federally Qualified Health Center (FQHC) 6204804883 Practice locations: Cameron Park, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073981783. Details of each certification follow.

Federally qualified health center certification: CCN 751859

Legal name
EL DORADO COUNTY COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 3, 2016
Last certification
Mar 3, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
3100 Ponte Morino Dr
Ste 120
Cameron Park, CA 95682-7450

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
El Dorado County Community Health C5 organizations share this tax ID, including this one
Part of
El Dorado County Community Health C

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4327 Golden Center Dr
Ste 2
Placerville, CA 95667

4641 Missouri Flat Rd
Placerville, CA 95667
Phone (510) 642-0749

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Jonas Kriks Individual Corporate DirectorBoard Member Jun 1, 2017
Kevin Monsma Individual Corporate DirectorBoard Member Oct 1, 2018
Andrea Campbell Individual Corporate DirectorBoard Member Aug 1, 2022
Ben Young Individual Corporate DirectorBoard Member Mar 1, 2019
Michael a Ungeheurer Individual Corporate DirectorBoard Member Jan 1, 2015
Terri Stratton Individual Corporate OfficerChief Executive Officer Jan 6, 2014
W-2 Managing EmployeeChief Executive Officer Jan 6, 2014
Doris E Blumenthal Individual Corporate DirectorBoard Member Jan 1, 2015
Rachel Peigh Individual Corporate DirectorBoard Member Jun 1, 2022
Chris Barton Individual Corporate DirectorBoard Member Jan 1, 2022
El Dorado County Community Health Center Organization, Placerville, CA Corporation, Non-profit Other Oct 1, 2015
Thomas Detro Ewing Individual Corporate DirectorBoard Member Jun 1, 2022
Carol Herrlie Individual Corporate DirectorBoard Member Mar 1, 2019
Judy Stein Individual Corporate OfficerChief Financial Officer Jan 14, 2008
W-2 Managing EmployeeChief Financial Officer Jan 14, 2008
Glenn Lawson Individual Corporate DirectorBoard Member Sep 27, 2022

Owners & managing parties with NPI records 2

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

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
El Dorado County Community Health CenterCameron Park, CA, CCN 751166 Federally qualified health center Other Feb 1, 2015

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 17

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.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1441929600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700524800000",
    "number": "1073981783",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4212 MISSOURI FLAT RD",
            "city": "PLACERVILLE",
            "state": "CA",
            "postal_code": "956676269",
            "telephone_number": "530-621-7700",
            "fax_number": "530-621-7713"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3100 PONTE MORINO DR",
            "address_2": "SUITE 120",
            "city": "CAMERON PARK",
            "state": "CA",
            "postal_code": "956827432",
            "telephone_number": "530-621-7700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EL DORADO COUNTY COMMUNITY HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EL DORADO COUNTY COMMUNITY HEALTH CENTER",
        "enumeration_date": "2015-09-11",
        "last_updated": "2023-11-21",
        "certification_date": "2023-11-21",
        "status": "A",
        "authorized_official_last_name": "STEIN",
        "authorized_official_first_name": "JUDY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "530-748-2327",
        "authorized_official_credential": "CFO"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": null,
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "El Dorado Community Health Center Cameron Park Main",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "El Dorado Community Health Center Cameron Park Main",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cameron Park, CA

Sources for this page

Verify at the official NPI Registry.