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Venice Family Clinic

Organization Active NPI Federally Qualified Health Center (FQHC) · Venice, CA

NPI 1124054564 · NPPES record last updated Sep 7, 2023

Key facts

NPI
1124054564
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
VENICE FAMILY CLINIC
Practice address
905 Venice Blvd
Venice, CA 90291-4904
Phone
(310) 392-8638
NPI assigned
Jun 25, 2006
Organization subpart
Yes
Parent organization (as reported)
VENICE FAMILY CLINIC

Authorized official

Name
Dr. Mitesh G Popat, MD NPI 1104057397
Title
Chief Executive Officer
Phone
(310) 664-7901

Authorized official NPPES reports the authorized official by name only; the link goes to the one practitioner connected to this organization with that name.

Owners & managing parties with NPI records 1

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

  • Mitesh G Popat, MD Family Medicine Physician · Venice, CA · NPI 1104057397
    CMS ownership CORPORATE OFFICER · W-2 MANAGING EMPLOYEE

Owned or controlled facilities with NPI records 4

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

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 16

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

Practitioners 168

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

View all 168

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in CA

Federally qualified health center certification: CCN 751198

Legal name
VENICE FAMILY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 31, 2015
Last certification
Jul 31, 2015
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Aug 31, 1973 in CA
Enrollment address
905 Venice Blvd
Venice, CA 90291-4904

All disclosed owners & managing parties 23

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

NameRoleSinceShare
Joan Herman
Individual 		Corporate Director
Treasurer		 Jun 1, 2019
Joanne Bourne
Individual 		Corporate Director
Board Member		 Jun 1, 2022
Michael St Pierre
Individual 		Corporate Director
Board Member		 Jul 1, 2016
Taryn a Keane
Individual 		Corporate Director
Board Member		 Jul 1, 2019
Jeffrey E Sinaiko
Individual 		Corporate Director
Board Chair		 Jul 1, 2015
Yesenia Gallegos
Individual 		Corporate Director
Board Member		 Jun 1, 2020
John Geresi
Individual 		Corporate Director
Board Member		 Jul 26, 2016
Joy Higa
Individual 		Corporate Director
Board Member		 Aug 1, 2023
Jennifer Campos
Individual 		Corporate Director
Board Member		 Jun 15, 2024
Carolina Monge
Individual 		Corporate Director
Board Member		 Oct 1, 2017
Kenrick Bascom
Individual 		Corporate Director
Board Member		 Apr 1, 2017
Susan Fleischman
Individual 		Corporate Director
Vice Chair		 Jun 20, 2020
Matthew James Kinney
Individual 		Corporate Director
Board Member		 Aug 1, 2023
Isabela Mihai
Individual 		Corporate Officer
Chief Compliance Officer		 Oct 14, 2024 10%
W-2 Managing Employee
Chief Compliance Officer		 Oct 14, 2024 10%
Operational/Managerial Control
Chief Compliance Officer		 Oct 14, 2024 10%
Hilda Pena
Individual 		Corporate Director
Board Member		 Apr 1, 2023
Sergio D Bautista
Individual 		Corporate Officer
Chief Financial Officer		 Sep 15, 2025 10%
W-2 Managing Employee
Chief Financial Officer		 Sep 15, 2025 10%
Operational/Managerial Control
Chief Financial Officer		 Sep 15, 2025 10%
Mark R Gavens
Individual 		Corporate Director
Board Chair		 Jun 1, 2020
Michele L Delmonico
Individual 		Corporate Director
Board Member		 Jun 1, 2020
Olga Carrasco
Individual 		Corporate Director
Board Member		 Jul 1, 2016
Mayer B Davidson
Individual 		Corporate Director
Co Founder;Board Member; Chair,		 Jul 1, 2015
Mitesh Popat
Individual 		Corporate Officer
Ceo		 Dec 22, 2022
W-2 Managing Employee
Ceo		 Dec 22, 2022
Diana Carsola
Individual 		Corporate Director
Board Member		 Jul 1, 2016
Sharon L Gelfand
Individual 		Corporate Director
Board Member		 Jun 1, 2020

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Venice Family Clinic-Bills Clinic at Safe Place for Youth
Venice, CA · CCN 751948		 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family Clinic-Santa Monica High School
Santa Monica, CA · CCN 751960		 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family Clinic
Carson, CA · CCN 751055		 Federally qualified health center 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Oct 1, 2021
Oct 1, 2021
Venice Family Clinic - Sandy Segal Youth Health Center
Culver City, CA · CCN A01923		 Federally qualified health center Operational/Managerial Control Feb 1, 2017

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20031217001082 CA Part B Supplier - Clinic/Group Practice 2264339126 Receives reassigned benefits from 149 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Culver City, CA; Santa Monica, CA; Venice, CA
O20150813009805 CA Part a Provider - Federally Qualified Health Center (FQHC) 2264339126 Practice locations: Venice, CA

National Provider Directory

Part of
Venice Family Clinic-Robert

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X 960000959 CA
Federally Qualified Health Center (FQHC) 261QF0400X Yes

Addresses

Primary practice location

905 Venice Blvd
Venice, CA 90291-4904

Mailing address

604 Rose Ave
Venice, CA 90291-2767
Phone (310) 392-8636

Other names

  • Robert Levine Family Health Center Other name

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Sep 7, 2023.

{
    "created_epoch": "1151193600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694044800000",
    "number": "1124054564",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "604 ROSE AVE",
            "city": "VENICE",
            "state": "CA",
            "postal_code": "902912767",
            "telephone_number": "310-392-8636"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "905 VENICE BLVD",
            "city": "VENICE",
            "state": "CA",
            "postal_code": "902914904",
            "telephone_number": "310-392-8638"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VENICE FAMILY CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "VENICE FAMILY CLINIC",
        "enumeration_date": "2006-06-25",
        "last_updated": "2023-09-07",
        "certification_date": "2023-09-07",
        "status": "A",
        "authorized_official_last_name": "POPAT",
        "authorized_official_first_name": "MITESH",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "310-664-7901",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "CA",
            "license": "960000959",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Robert Levine Family Health Center",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Robert Levine Family Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Venice, CA

All providers in Venice, CA · Federally Qualified Health Center (FQHC) in California

Sources for this page

Verify at the official NPI Registry.