NPIMap

Organization Active NPI

Alameda Health System

Doing business as Eastmont Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Oakland, CA
National Provider Identifier
1104959089
Registry record updated Jul 5, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
EXEMPT UNDER 12-35B Issued in CA
Legal business name
ALAMEDA HEALTH SYSTEM
Doing business as
Eastmont Wellness Center
Practice address
6955 Foothill Blvd Suite 200
Oakland, CA 94605-2409
Phone
(510) 567-5704
Fax
(510) 568-0225
NPI assigned
Mar 13, 2007
Last updated
Jul 5, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 5, 2023

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

Authorized official

Name
Kim Miranda
Title
Cfo
Phone
(510) 618-2147

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X EXEMPT UNDER 12-35B CA Primary
Case Manager/Care Coordinator 171M00000X NU

Addresses

Primary practice location

6955 Foothill Blvd Suite 200
Oakland, CA 94605-2409

Mailing address

15400 Foothill Blvd
San Leandro, CA 94578-1009
Phone (510) 895-7344

Other identifiers 6

IdentifierTypeStateIssuer
HAP11783GMedicaidCA
FHC11783GMedicaidCA
000001116OtherCADD PRIVATE - EASTMONT
G01016-03OtherCAAA DELTA DENTAL
BCP11783GMedicaidCA
10449OtherCAHF ACCESS DNTL - EASTMNT

Other names 1

  • EASTMONT 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
O20160128000570 CA Part A Provider - Federally Qualified Health Center (FQHC) 3779494521 Practice locations: Oakland, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104959089. Details of each certification follow.

Federally qualified health center certification: CCN 751805

Legal name
ALAMEDA HEALTH SYSTEM
Doing business as
EASTMONT WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 3, 2015
Last certification
Dec 3, 2015
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Incorporated
in CA
Enrollment address
6955 Foothill Blvd
Ste 200
Oakland, CA 94605-2426

Other NPIs with the same Medicare PAC ID 10

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

National Provider Directory

National Provider Directory
Tax ID family
Ambulatory Care Service39 organizations share this tax ID, including this one

Other organizations with this tax ID 38

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

View all 38

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Frederick J Devries Individual Corporate Officer Oct 8, 2013
Corporate Director Oct 8, 2013
David W Cox Individual Corporate OfficerChief Financial Officer Jul 14, 2014
Corporate DirectorChief Financial Officer Jul 14, 2014
W-2 Managing EmployeeChief Financial Officer Jul 14, 2014
Maria G Hernandez Individual Corporate Director May 13, 2014
Anthony B Varni Individual Corporate Director Mar 26, 2013
Tracy Jensen Individual Corporate Director Sep 9, 2014
James Lugannani Individual Corporate Director Sep 9, 2014
John T Chapman Individual Corporate OfficerChief Administrative Officer Dec 5, 2011
W-2 Managing EmployeeChief Administrative Officer Dec 5, 2011
Barooyr F Zorthian Individual Corporate Director Feb 1, 2011
James E Jackson Individual Corporate Officer May 14, 2012
W-2 Managing Employee May 14, 2012
Kirk E Miller Individual Corporate Director Dec 19, 2006
Kinkini Banerjee Individual Corporate Director Oct 8, 2013
Shari Johnson Individual Corporate Officer Jun 24, 2024
W-2 Managing EmployeeAd; Jun 24, 2024
Michele Lawrence Individual Corporate Director Nov 20, 2012

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
John George Psychiatric HospitalSan Leandro, CA, CCN 05S320 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1998
San Leandro Hospital Rehabilitation UnitSan Leandro, CA, CCN 05T320 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1998
Alameda Health SystemAlameda, CA, CCN 050211 Hospital Other (100%) May 1, 2014
Fairmont HospitalSan Leandro, CA, CCN 056479 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1998
Hayward Wellness CenterHayward, CA, CCN 751807 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Sep 18, 1998

Owned or controlled facilities with NPI records 6

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

NPI Registry JSON

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

{
    "created_epoch": "1173744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1688515200000",
    "number": "1104959089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15400 FOOTHILL BLVD",
            "city": "SAN LEANDRO",
            "state": "CA",
            "postal_code": "945781009",
            "telephone_number": "510-895-7344",
            "fax_number": "510-895-7229"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6955 FOOTHILL BLVD SUITE 200",
            "city": "OAKLAND",
            "state": "CA",
            "postal_code": "946052409",
            "telephone_number": "510-567-5704",
            "fax_number": "510-568-0225"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALAMEDA HEALTH SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-13",
        "last_updated": "2023-07-05",
        "certification_date": "2023-07-05",
        "status": "A",
        "authorized_official_last_name": "MIRANDA",
        "authorized_official_first_name": "KIM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "510-618-2147"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "EXEMPT UNDER 12-35B",
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HAP11783G",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC11783G",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DD PRIVATE - EASTMONT",
            "identifier": "000001116",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AA DELTA DENTAL",
            "identifier": "G01016-03",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "BCP11783G",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HF ACCESS DNTL - EASTMNT",
            "identifier": "10449",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "EASTMONT WELLNESS CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "EASTMONT WELLNESS CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Oakland, CA

Sources for this page

Verify at the official NPI Registry.