NPIMap

Organization Active NPI

El Dorado County Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Placerville, CA
National Provider Identifier
1316050107
Registry record updated Nov 21, 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
Practice address
4212 Missouri Flat Rd
Placerville, CA 95667-6269
Phone
(530) 621-7700
Fax
(530) 621-7713
NPI assigned
Aug 16, 2006
Last updated
Nov 21, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 21, 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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Case Manager/Care Coordinator 171M00000X NU

Addresses

Primary practice location

4212 Missouri Flat Rd
Placerville, CA 95667-6269

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
FHC70987FMedicaidCA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040921001072 CA Part A Provider - Federally Qualified Health Center (FQHC) 6204804883 Practice locations: Placerville, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1316050107. Details of each certification follow.

Federally qualified health center certification: CCN 551988

Legal name
EL DORADO COUNTY COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 9, 2004
Last certification
Nov 9, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 2002 in CA
Enrollment address
4212 Missouri Flat Rd
Placerville, CA 95667-6269

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

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 13

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 DirectorBoard Member Jun 1, 2017
Kevin Monsma Individual Corporate DirectorVice Chair Oct 1, 2008
Andrea Campbell Individual Corporate DirectorBoard Member Aug 1, 2022
Ben Young Individual Corporate DirectorBoard Member Mar 1, 2019
Michael a Ungeheurer Individual Corporate OfficerBoard Member Nov 14, 2002
Doris E Blumenthal Individual Corporate OfficerBoard Member Sep 23, 2008
Rachel Peigh Individual Corporate DirectorBoard Member Jun 1, 2022
Chris Barton Individual Corporate DirectorBoard Member Jan 1, 2022
Thomas Detro Ewing Individual Corporate DirectorBoard Member Jun 1, 2022
Carol Herrlie Individual Corporate DirectorBoard Member Mar 1, 2019
Caleb Sandford Individual Corporate OfficerChief Executive Officer Sep 26, 2022
W-2 Managing EmployeeChief Executive Officer Sep 26, 2022
Judy Stein Individual Corporate OfficerChief Financial Officer Jan 14, 2008
W-2 Managing EmployeeChief Financial Officer Jan 14, 2008
Glenn Lawson Individual Corporate DirectorBoard Member Sep 27, 2022

All facility ownership & control disclosures 2

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 751166 Federally qualified health center Other Feb 1, 2015
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 2

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

Practitioners & affiliated clinicians

Practitioners 27

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 27

NPI Registry JSON

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

{
    "created_epoch": "1155686400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700524800000",
    "number": "1316050107",
    "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": "4212 MISSOURI FLAT RD",
            "city": "PLACERVILLE",
            "state": "CA",
            "postal_code": "956676269",
            "telephone_number": "530-621-7700",
            "fax_number": "530-621-7713"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EL DORADO COUNTY COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-16",
        "last_updated": "2023-11-21",
        "certification_date": "2023-11-21",
        "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
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70987F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Placerville, CA

Sources for this page

Verify at the official NPI Registry.