NPIMap

Organization Active NPI

Community Medical Centers, Inc

Doing business as Community Medical Centers, Waterloo

  • Federally Qualified Health Center (FQHC)
  • Stockton, CA
National Provider Identifier
1285059923
Registry record updated Jun 16, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COMMUNITY MEDICAL CENTERS, INC
Doing business as
Community Medical Centers, Waterloo
Practice address
1031 Waterloo Rd
Stockton, CA 95205-4256
Phone
(209) 940-5600
Fax
(209) 940-5065
NPI assigned
Mar 4, 2014
Last updated
Jun 16, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2015

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

Authorized official

Name
Mr. Art Feagles
Title
Cfo
Phone
(209) 373-2803

Specialties & licenses 1

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

Addresses

Primary practice location

1031 Waterloo Rd
Stockton, CA 95205-4256

Mailing address

7210 Murray Dr
Stockton, CA 95210-3339
Phone (209) 373-2800

Other names 1

  • Community Medical Centers, Waterloo Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20101027000870 CA Part B Supplier - Clinic/Group Practice 8426968520 Receives reassigned benefits from 171 practitioners
18 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Vacaville, CA; Tracy, CA; Stockton, CA; Manteca, CA; Lodi, CA; Esparto, CA; Dixon, CA
O20141112002250 CA Part A Provider - Federally Qualified Health Center (FQHC) 8426968520 Practice locations: Stockton, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285059923. Details of each certification follow.

Federally qualified health center certification: CCN 751148

Legal name
COMMUNITY MEDICAL CENTERS, INC.
Doing business as
COMMUNITY MEDICAL CENTERS WATERLOO
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 14, 2014
Last certification
Nov 14, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 9, 1978 in CA
Enrollment address
1031 Waterloo Rd
Stockton, CA 95205-4256

Other NPIs with the same Medicare PAC ID 24

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

View all 24

Other NPIs on the same Medicare enrollment 18

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

View all 18

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Ruby V King Individual Corporate DirectorBoard Member Jul 1, 2018
Jaime DG Allen Individual Corporate OfficerCfo Jan 1, 2019
Lily Aman Individual Corporate DirectorBoard Member Jul 1, 1989
Robert Smith Individual Corporate DirectorBoard Member Jul 1, 2013
Pamela Maffei Individual Corporate DirectorBoard Member Jul 1, 2011
Dora Vivero Individual W-2 Managing EmployeeDirector of Revenue Cycle Sep 12, 2014
Christine C Noguera Individual Corporate OfficerCeo Jul 2, 2014
Jasmine Leek Individual Corporate DirectorBoard Member Jul 1, 2015
Roger Speed Individual Corporate DirectorBoard Member Jul 1, 2004
Peter W Ragsdale Individual Corporate DirectorBoard Member Jul 1, 2018
Martha Dukes Individual Corporate DirectorBoard Member Jul 1, 1985

Practitioners & affiliated clinicians

Practitioners 9

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.

NPI Registry JSON

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

{
    "created_epoch": "1393891200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1434412800000",
    "number": "1285059923",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7210 MURRAY DR",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952103339",
            "telephone_number": "209-373-2800",
            "fax_number": "209-373-2879"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1031 WATERLOO RD",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952054256",
            "telephone_number": "209-940-5600",
            "fax_number": "209-940-5065"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY MEDICAL CENTERS, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-04",
        "last_updated": "2015-06-16",
        "status": "A",
        "authorized_official_last_name": "FEAGLES",
        "authorized_official_first_name": "ART",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "209-373-2803",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Community Medical Centers, Waterloo",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Stockton, CA

Sources for this page

Verify at the official NPI Registry.