NPIMap

Organization Active NPI

The Davis Street Community Center Incorporated

Doing business as Davis Street Primary Care Clinic

  • Federally Qualified Health Center (FQHC)
  • San Leandro, CA
National Provider Identifier
1215358924
Registry record updated Apr 1, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
THE DAVIS STREET COMMUNITY CENTER INCORPORATED
Doing business as
Davis Street Primary Care Clinic
Practice address
3081 Tegarden
San Leandro, CA 94577-5720
Phone
(510) 347-4620
Fax
(510) 486-4486
NPI assigned
Dec 23, 2013
Last updated
Apr 1, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2020

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

Authorized official

Name
Rosalia Aquino McMillen
Title
Chief Fiscal Officer
Phone
(510) 347-4620

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Adult Mental Health Clinic/Center 261QM0850X

Addresses

Primary practice location

3081 Tegarden
San Leandro, CA 94577-5720

Mailing address

3081 Tegarden Street
San Leandro, CA 94577-5720
Phone (510) 347-4620

Other names 1

  • Davis Street Primary Care Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20141204000241 CA Part B Supplier - Clinic/Group Practice 6800956079 Receives reassigned benefits from 43 practitioners
Practice locations: San Leandro, CA
O20160208001501 CA Part A Provider - Federally Qualified Health Center (FQHC) 6800956079 Practice locations: San Leandro, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1215358924. Details of each certification follow.

Federally qualified health center certification: CCN 751806

Legal name
THE DAVIS STREET COMMUNITY CENTER INCORPORATED
Doing business as
DAVIS STREET PRIMARY CARE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 16, 2016
Last certification
Feb 16, 2016
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Enrollment address
3081 Teagarden St
San Leandro, CA 94577-5720

National Provider Directory

National Provider Directory
Tax ID family
Davis Street Community Center2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/9743/brand/1/csg/1/fhir/r4

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Daniel Johnson Individual Corporate OfficerChief Executive Officer Feb 12, 2025
Dmitri Lebedev Individual W-2 Managing EmployeeClinic Operations Manager Dec 29, 2015
Tracy Steele Individual Corporate DirectorBoard Member Jul 1, 2015 8.33%
Gordon Galvan Individual Corporate DirectorPresident Jun 1, 2008 8.33%
Nancy Pretto Individual Corporate DirectorSecretary Jul 1, 2013 8.33%
Apurv Gujral Individual Corporate DirectorBoard Member Jun 1, 2013 8.33%
Rosalia Aquino McMillen Individual Corporate OfficerCfo May 8, 2013
W-2 Managing EmployeeCfo May 8, 2013 100%
Katherine Frates Individual Corporate DirectorBoard Member Jun 1, 2012 8.33%
Patrick Sangiacomo Individual Corporate DirectorTreasurer Jul 1, 2014 8.33%
Mika Hiramatsu Individual Corporate DirectorBoard Member Jun 1, 1994 8.33%

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 44

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 44

NPI Registry JSON

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

{
    "created_epoch": "1387756800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1585699200000",
    "number": "1215358924",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3081 TEGARDEN STREET",
            "city": "SAN LEANDRO",
            "state": "CA",
            "postal_code": "945775720",
            "telephone_number": "510-347-4620",
            "fax_number": "510-486-4486"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3081 TEGARDEN",
            "city": "SAN LEANDRO",
            "state": "CA",
            "postal_code": "945775720",
            "telephone_number": "510-347-4620",
            "fax_number": "510-486-4486"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE DAVIS STREET COMMUNITY CENTER INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-23",
        "last_updated": "2020-04-01",
        "certification_date": "2020-04-01",
        "status": "A",
        "authorized_official_last_name": "MCMILLEN",
        "authorized_official_first_name": "ROSALIA",
        "authorized_official_middle_name": "AQUINO",
        "authorized_official_title_or_position": "CHIEF FISCAL OFFICER",
        "authorized_official_telephone_number": "510-347-4620"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Davis Street Primary Care Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Davis Street Primary Care Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Leandro, CA

Sources for this page

Verify at the official NPI Registry.