Prime Wellness Community Health Center

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

PRIME WELLNESS COMMUNITY HEALTH CENTER

Practice address

8610 S Sepulveda Blvd Ste 104
Los Angeles, CA 90045-4009

Phone

(310) 659-7867

Fax

(310) 878-2118

NPI assigned

Dec 3, 2019

Organization subpart

No

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

Authorized official

Name

Denys Slesarenko

Title

Ceo

Phone

(310) 659-7867

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083251532. Details of each certification follow.

• CCN A01880 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN A01880

Legal name

PRIME WELLNESS COMMUNITY HEALTH CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Oct 4, 2024

Last certification

Oct 4, 2024

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Incorporated

Feb 11, 2019 in CA

Enrollment address

8610 S Sepulveda Blvd
Ste 104
Los Angeles, CA 90045-4009

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

All disclosed owners & managing parties 10

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

Owners & managing parties with NPI records 1

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

• Lamar A. Nelson, MD

  • Dermatology Physician
  • Los Angeles, CA
  • NPI 1962579987

  Corporate Director

  CMS ownership

Practitioners 3

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.

• Nicolette Lee Ballou, MD

  • Pediatrics Physician
  • Beverly Hills, CA
  • NPI 1457420077
  Medicare reassignment NPD
• Rick Chavez, MD

  • Pain Medicine Physician
  • Redondo Beach, CA
  • NPI 1144271495
  NPD (past)
• Liliana Beatriz Krebs, FNP-BC

  • Family Nurse Practitioner
  • Los Angeles, CA
  • NPI 1144046129
  NPD (past)

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

{
    "created_epoch": "1575331200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1788134400000",
    "number": "1083251532",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8610 S SEPULVEDA BLVD STE 104",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900454009",
            "telephone_number": "310-659-7867",
            "fax_number": "310-878-2118"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8610 S SEPULVEDA BLVD STE 104",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900454009",
            "telephone_number": "310-659-7867",
            "fax_number": "310-878-2118"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "133 N Prairie Ave Ste B",
            "address_purpose": "LOCATION",
            "city": "Inglewood",
            "state": "CA",
            "postal_code": "903014879",
            "country_code": "US",
            "telephone_number": "310-419-2223",
            "fax_number": "310-419-2226",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PRIME WELLNESS COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-03",
        "last_updated": "2026-08-31",
        "certification_date": "2026-08-31",
        "status": "A",
        "authorized_official_last_name": "SLESARENKO",
        "authorized_official_first_name": "DENYS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "310-659-7867"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Federally Qualified Health Center (FQHC) in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Federally Qualified Health Center (FQHC) in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.