NPIMap

Organization Active NPI

Chapa-de Indian Health Program, Inc.

  • Federally Qualified Health Center (FQHC)
  • Auburn, CA
National Provider Identifier
1114057163
Registry record updated Jan 3, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
030000189 Issued in CA
Legal business name
CHAPA-DE INDIAN HEALTH PROGRAM, INC.
Practice address
11670 Atwood Rd
Auburn, CA 95603-9522
Phone
(530) 887-2800
Fax
(530) 887-2807
NPI assigned
Mar 7, 2007
Last updated
Jan 3, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 3, 2018

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

Authorized official

Name
Mr. Sierk Haitsma
Title
Chief Financial Officer
Phone
(530) 889-2841

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 030000189 CA Primary

Addresses

Primary practice location

11670 Atwood Rd
Auburn, CA 95603-9522

Mailing address

11670 Atwood Rd
Auburn, CA 95603-9522
Phone (530) 887-2800

Other identifiers 1

IdentifierTypeStateIssuer
THP12027FMedicaidCA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040614000473 CA Part B Supplier - Clinic/Group Practice 4981688520 Receives reassigned benefits from 81 practitioners
Practice locations: Grass Valley, CA; Auburn, CA
O20111013000174 CA Part A Provider - Federally Qualified Health Center (FQHC) 4981688520 Practice locations: Auburn, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114057163. Details of each certification follow.

Federally qualified health center certification: CCN 051922

Legal name
CHAPA-DE INDIAN HEALTH PROGRAM, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
Non-profit – other
Organization structure
CorporationNon-profit
Incorporated
Jun 5, 1979 in CA
Enrollment address
11670 Atwood Rd
Auburn, CA 95603-9522

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

Locations

175 W Main St
Woodland, CA 95695
Phone (530) 661-4400

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/AHHIAD

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Lisa Davies Individual Corporate OfficerChief Executive Officer Jul 5, 2010
Chapa-de Indian Health Program, Inc. Organization, Auburn, CA Non-profit Other Jun 5, 1979
Darla Clark Individual Corporate OfficerChief Operations Officer Dec 1, 2010
Emilian Radu Individual W-2 Managing Employee Jan 1, 2019
Sierk Haitsma Individual Corporate OfficerCfo Jul 21, 2010

Owners & managing parties with NPI records 1

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
Chapa-de Indian Health Program, Inc.Grass Valley, CA, CCN 551868 Federally qualified health center Other Jun 5, 1979

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 81

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 81

NPI Registry JSON

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

{
    "created_epoch": "1173225600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1514937600000",
    "number": "1114057163",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11670 ATWOOD RD",
            "city": "AUBURN",
            "state": "CA",
            "postal_code": "956039522",
            "telephone_number": "530-887-2800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11670 ATWOOD RD",
            "city": "AUBURN",
            "state": "CA",
            "postal_code": "956039522",
            "telephone_number": "530-887-2800",
            "fax_number": "530-887-2807"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHAPA-DE INDIAN HEALTH PROGRAM, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-07",
        "last_updated": "2018-01-03",
        "status": "A",
        "authorized_official_last_name": "HAITSMA",
        "authorized_official_first_name": "SIERK",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "530-889-2841",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "030000189",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "THP12027F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Auburn, CA

Sources for this page

Verify at the official NPI Registry.