NPIMap

Organization Active NPI

Venice Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Venice, CA
National Provider Identifier
1124054564
Registry record updated Sep 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Sep 7, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
VENICE FAMILY CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 7, 2023

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

Authorized official

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

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

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

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 1

  • Robert Levine Family Health Center Other name

Medicare participation

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

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124054564. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Aug 31, 1973 in CA
Enrollment address
905 Venice Blvd
Venice, CA 90291-4904

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Other NPIs on the same Medicare enrollment 4

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

National Provider Directory

National Provider Directory
Part of
Venice Family Clinic

Locations

905 Venice Blvd
Venice, CA 90291
Phone (310) 392-8630

Ownership & related parties

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

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 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 YouthVenice, CA, CCN 751948 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family Clinic-Santa Monica High SchoolSanta Monica, CA, CCN 751960 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family ClinicCarson, 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 CenterCulver City, CA, CCN A01923 Federally qualified health center Operational/Managerial Control Feb 1, 2017

Owned or controlled facilities with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 121

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 121

NPI Registry JSON

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

{
    "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

Sources for this page

Verify at the official NPI Registry.