NPIMap

Organization Active NPI

Watts Healthcare Corporation

  • Federally Qualified Health Center (FQHC)
  • Los Angeles, CA
National Provider Identifier
1104246362
Registry record updated May 23, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
550002583 Issued in CA
Legal business name
WATTS HEALTHCARE CORPORATION
Practice address
316 E 111TH St
Los Angeles, CA 90061-3004
Phone
(323) 568-3093
NPI assigned
Apr 25, 2014
Organization subpart
Yes
Parent organization
WATTS HEALTHCARE CORPORATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 23, 2023

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

Authorized official

Name
David Brumlage
Title
Assistant Controller
Phone
(323) 564-4331

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550002583 CA Primary

Addresses

Primary practice location

316 E 111TH St
Los Angeles, CA 90061-3004

Mailing address

10300 Compton Ave
Los Angeles, CA 90002-3628
Phone (323) 357-6680

Other identifiers 2

IdentifierTypeStateIssuer
1104246362MedicaidCA
1477649119MedicaidCA

Other names 1

  • Locke Wellness Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230608000422 CA Part A Provider - Federally Qualified Health Center (FQHC) 0446161533 Practice locations: Los Angeles, CA

Federally qualified health center certification: CCN A01154

Legal name
WATTS HEALTHCARE CORPORATION
Doing business as
LOCKE WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 5, 2023
Last certification
Jun 5, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 1, 2003 in CA
Enrollment address
316 E 111TH St
Los Angeles, CA 90061-3004

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory
Tax ID family
Watts Health Center5 organizations share this tax ID, including this one
Part of
Watts Health Center

Other organizations with this tax ID 4

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

Locations

316 E 111th St
Los Angeles, CA 90061
Phone (323) 418-1055

2265 E 103rd St
Los Angeles, CA 90002
Phone (323) 564-4331

3756 Santa Rosalia Dr
Ste 400
Los Angeles, CA 90008
Phone (323) 290-3400

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Osazuwa Omede Individual Corporate Director Jan 1, 2011
Victor Cortez Individual Corporate Director Apr 3, 2003
Oliver T Brooks Individual Corporate Officer Jan 17, 2023
Olusheyi Lawoyin Individual Corporate Officer Feb 1, 2019 100%
Operational/Managerial Control Feb 1, 2019 100%
Haregewoin Yohannes Individual Corporate Officer Jan 1, 2020
Glenn C Ford Individual Corporate Director Apr 1, 2021
Joe Waller Individual Corporate Director Apr 1, 2003

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1398384000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1684800000000",
    "number": "1104246362",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10300 COMPTON AVE",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900023628",
            "telephone_number": "323-357-6680"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "316 E 111TH ST",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900613004",
            "telephone_number": "323-568-3093"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATTS HEALTHCARE CORPORATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WATTS HEALTHCARE CORPORATION",
        "enumeration_date": "2014-04-25",
        "last_updated": "2023-05-23",
        "certification_date": "2023-04-13",
        "status": "A",
        "authorized_official_last_name": "BRUMLAGE",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "ASSISTANT CONTROLLER",
        "authorized_official_telephone_number": "323-564-4331"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "550002583",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1104246362",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1477649119",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Locke Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Locke Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Los Angeles, CA

Sources for this page

Verify at the official NPI Registry.