NPIMap

Organization Active NPI

St. Jude Neighborhood Health Centers

  • Primary Care Clinic/Center
  • Fullerton, CA
National Provider Identifier
1316206592
Registry record updated Jun 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Practice address
731 S Highland Ave
Fullerton, CA 92832-2753
Phone
(714) 446-5100
Fax
(714) 449-0726
NPI assigned
May 9, 2012
Last updated
Jun 17, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2020

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

Authorized official

Name
Timothy Jason Brown
Title
Chief Executive Officer
Phone
(208) 899-9631

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Dental Clinic/Center 261QD0000X
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

731 S Highland Ave
Fullerton, CA 92832-2753

Mailing address

731 S Highland Ave
Fullerton, CA 92832-2753
Phone (714) 446-5100

Other names 1

  • St. Jude Neighborhood Health Center Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140131001141 CA Part A Provider - Federally Qualified Health Center (FQHC) 4284886789 Practice locations: Fullerton, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1316206592. Details of each certification follow.

Federally qualified health center certification: CCN 751048

Legal name
ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 31, 2014
Last certification
Jan 31, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 25, 2011 in CA
Enrollment address
731 S Highland Ave
Fullerton, CA 92832-2753

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

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
Herlinda E Ramirez Machado Individual Corporate Director Mar 27, 2018
Sheri Lindholm Individual Corporate Director Jul 1, 2020
Sonia Martinez Individual Corporate Director Jun 1, 2020
Julieta Barraza Individual Corporate Director Jul 1, 2020
Craig Harris Individual Corporate Director Aug 1, 2021
St. Jude Neighborhood Health Centers Organization, Fullerton, CA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Oct 25, 2011 100%
Maureen Sundberg Individual Corporate Director Aug 1, 2021
Mark Jablonski Individual Corporate Director Apr 1, 2020
Juan Garcia Individual Corporate Director Jun 1, 2016
Timothy Jason Brown Individual Corporate OfficerCeo Oct 22, 2012
W-2 Managing EmployeeCeo Oct 22, 2012
Cecilia Bustamante-Pixa Individual Corporate Director Mar 1, 2020
Daniel S Kim Individual Corporate Director May 17, 2023
Sylvia Reyes Individual Corporate Director Mar 27, 2018

Owners & managing parties with NPI records 6

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
St. Jude Neighborhood Health CentersFullerton, CA, CCN 751143 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2015
St. Jude Neighborhood Health CentersSanta Ana, CA, CCN 751172 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 4, 2015
R1 RCMOrange, CA, CCN 921100 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Aug 1, 2018
St. Mary Health Centers - AdelantoAdelanto, CA, CCN A01062 Federally qualified health center 5% Or Greater Direct Ownership Interest Aug 24, 2020
St. Mary Health Centers - AvApple Valley, CA, CCN A01063 Federally qualified health center 5% Or Greater Direct Ownership Interest Aug 24, 2020

Owned or controlled facilities with NPI records 5

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

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

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

{
    "created_epoch": "1336521600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1592352000000",
    "number": "1316206592",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "731 S HIGHLAND AVE",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928322753",
            "telephone_number": "714-446-5100",
            "fax_number": "714-449-0726"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "731 S HIGHLAND AVE",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928322753",
            "telephone_number": "714-446-5100",
            "fax_number": "714-449-0726"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. JUDE NEIGHBORHOOD HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-09",
        "last_updated": "2020-06-17",
        "certification_date": "2020-06-17",
        "status": "A",
        "authorized_official_last_name": "BROWN",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "JASON",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "208-899-9631"
    },
    "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": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Jude Neighborhood Health Center",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "St. Jude Neighborhood Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Fullerton, CA

Sources for this page

Verify at the official NPI Registry.