NPIMap

Organization Active NPI

El Dorado County Community Health Center

Doing business as El Dorado Community Health Center Cameron Park

  • Federally Qualified Health Center (FQHC)
  • Cameron Park, CA
National Provider Identifier
1285044990
Registry record updated Mar 15, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EL DORADO COUNTY COMMUNITY HEALTH CENTER
Doing business as
El Dorado Community Health Center Cameron Park
Practice address
3104 Ponte Morino Dr
Suite 110
Cameron Park, CA 95682-8282
Phone
(530) 621-7700
Fax
(530) 621-7713
NPI assigned
May 2, 2014
Last updated
Mar 15, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
EL DORADO COUNTY COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 15, 2023

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

Authorized official

Name
Judy Stein
Title
Cfo
Phone
(530) 748-2327

Specialties & licenses 1

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

Addresses

Primary practice location

3104 Ponte Morino Dr
Suite 110
Cameron Park, CA 95682-8282

Mailing address

4212 Missouri Flat Rd
Placerville, CA 95667-6269
Phone (530) 621-7700

Other names 1

  • El Dorado Community Health Center Cameron Park Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150702002582 CA Part A Provider - Federally Qualified Health Center (FQHC) 6204804883 Practice locations: Cameron Park, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285044990. Details of each certification follow.

Federally qualified health center certification: CCN 751166

Legal name
EL DORADO COUNTY COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 1, 2015
Last certification
Jul 1, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
3104 Ponte Morino Dr 110
Cameron Park, CA 95682-8282

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
El Dorado County Community Health C5 organizations share this tax ID, including this one
Part of
El Dorado County Community Health C

Other organizations with this tax ID 4

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

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Jonas Kriks Individual Corporate Director Jun 1, 2017
Kevin Monsma Individual Corporate Director Oct 1, 2018
Andrea Campbell Individual Corporate Director Aug 1, 2020
Ben Young Individual Corporate Director Mar 1, 2019
Michael a Ungeheurer Individual Corporate Director Nov 14, 2002
Terri Stratton Individual W-2 Managing Employee Jan 16, 2014
Doris E Blumenthal Individual Corporate Director Feb 1, 2007
Rachel Peigh Individual Corporate Director Jun 1, 2022
Chris Barton Individual Corporate Director Jan 1, 2002
El Dorado County Community Health Center Organization, Placerville, CA Non-profit Other Feb 1, 2015
Thomas Detro Ewing Individual Corporate Director Jun 1, 2022
Carol Herrlie Individual Corporate Director Mar 1, 2019
Judy Stein Individual Corporate Officer Jan 14, 2008
W-2 Managing Employee Jan 14, 2008
Glenn Lawson Individual Corporate Director Sep 27, 2022

Owners & managing parties with NPI records 2

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
El Dorado County Community Health CenterCameron Park, CA, CCN 751859 Federally qualified health center Other Oct 1, 2015

Owned or controlled facilities with NPI records 1

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": "1398988800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678838400000",
    "number": "1285044990",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4212 MISSOURI FLAT RD",
            "city": "PLACERVILLE",
            "state": "CA",
            "postal_code": "956676269",
            "telephone_number": "530-621-7700",
            "fax_number": "530-621-7713"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3104 PONTE MORINO DR",
            "address_2": "SUITE 110",
            "city": "CAMERON PARK",
            "state": "CA",
            "postal_code": "956828282",
            "telephone_number": "530-621-7700",
            "fax_number": "530-621-7713"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EL DORADO COUNTY COMMUNITY HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EL DORADO COUNTY COMMUNITY HEALTH CENTER",
        "enumeration_date": "2014-05-02",
        "last_updated": "2023-03-15",
        "certification_date": "2023-03-15",
        "status": "A",
        "authorized_official_last_name": "STEIN",
        "authorized_official_first_name": "JUDY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "530-748-2327"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "El Dorado Community Health Center Cameron Park",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "El Dorado Community Health Center Cameron Park",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cameron Park, CA

Sources for this page

Verify at the official NPI Registry.