NPIMap

Organization Active NPI

St. Jude Neighborhood Health Centers

  • Primary Care Clinic/Center
  • Apple Valley, CA
National Provider Identifier
1316572563
Registry record updated Aug 4, 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
18077 Outer Hwy 18 Ste 100
Apple Valley, CA 92307-2168
Phone
(760) 946-8169
Fax
(760) 946-8875
NPI assigned
Mar 9, 2020
Last updated
Aug 4, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 4, 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

18077 Outer Hwy 18 Ste 100
Apple Valley, CA 92307-2168

Mailing address

18077 Outer Hwy 18 Ste 100
Apple Valley, CA 92307-2168

Other names 1

  • St. Mary Health Centers - Apple Valley Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220308000987 CA Part A Provider - Federally Qualified Health Center (FQHC) 4284886789 Practice locations: Apple Valley, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1316572563. Details of each certification follow.

Federally qualified health center certification: CCN A01063

Legal name
ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Doing business as
ST. MARY HEALTH CENTERS - AV
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 7, 2022
Last certification
Mar 7, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 25, 2011 in CA
Enrollment address
18077 US Highway 18
Ste 100
Apple Valley, CA 92307-2168

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

330 E Orangewood Ave
Anaheim, CA 92802
Phone (714) 446-5100

3232 Topaz Ln
Fullerton, CA 92831
Phone (714) 446-5230

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

17071 Main St
Ste 100
Hesperia, CA 92345
Phone (760) 956-7714

1801 S Greenville St
Santa Ana, CA 92704
Phone (714) 323-9135

Ownership & related parties

All disclosed owners & managing parties 17

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 Aug 24, 2020
Sheri Lindholm Individual Corporate Director Aug 24, 2020
Sonia Martinez Individual Corporate Director Aug 24, 2020
Judy Wagner Individual Corporate Director Aug 24, 2020
Julieta Barraza Individual Corporate Director Aug 24, 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 Aug 24, 2020
Daniel Estrada Individual Corporate Director Aug 24, 2020
Maureen Sundberg Individual Corporate Director Aug 1, 2021
Mark Jablonski Individual Corporate Director Aug 24, 2020
Gloria Dominguez Colazo Individual Corporate Director Aug 24, 2020
Juan Garcia Individual Corporate Director Aug 24, 2020
Timothy Jason Brown Individual Corporate Officer Aug 24, 2020
W-2 Managing EmployeeCeo Aug 24, 2020
Cecilia Bustamante-Pixa Individual Corporate Director Aug 24, 2020
Ronald R Diluigi Individual Corporate Director Aug 24, 2020
Sylvia Reyes Individual Corporate Director Aug 24, 2020
Sandra Even Individual Corporate Director Aug 24, 2020

Owners & managing parties with NPI records 5

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 751048 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 25, 2011
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

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.

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": "1583712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1596499200000",
    "number": "1316572563",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18077 OUTER HWY 18 STE 100",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "923072168"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18077 OUTER HWY 18 STE 100",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "923072168",
            "telephone_number": "760-946-8169",
            "fax_number": "760-946-8875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. JUDE NEIGHBORHOOD HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-09",
        "last_updated": "2020-08-04",
        "certification_date": "2020-08-04",
        "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": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Mary Health Centers - Apple Valley",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Apple Valley, CA

Sources for this page

Verify at the official NPI Registry.