NPIMap

Organization Active NPI

Mendocino Coast Clinics, Inc

  • Federally Qualified Health Center (FQHC)
  • Fort Bragg, CA
National Provider Identifier
1326335464
Registry record updated Oct 28, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MENDOCINO COAST CLINICS, INC
Practice address
510 Cypress St Ste D
Fort Bragg, CA 95437
Phone
(707) 964-5696
NPI assigned
Jul 8, 2011
Last updated
Oct 28, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
MENDOCINO COAST CLINICS, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 28, 2019

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

Authorized official

Name
Lucreshia Renteria
Title
Authorized Official
Phone
(707) 964-1251

Specialties & licenses 1

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

Addresses

Primary practice location

510 Cypress St Ste D
Fort Bragg, CA 95437

Mailing address

205 South St
Fort Bragg, CA 95437-5540
Phone (707) 964-1251

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120329000397 CA Part A Provider - Federally Qualified Health Center (FQHC) 5991619157 Practice locations: Fort Bragg, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1326335464. Details of each certification follow.

Federally qualified health center certification: CCN 551119

Legal name
MENDOCINO COAST CLINICS, INC
Doing business as
MENDOCINO COAST CLINICS PEDIATRIC GROUP
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 1, 2011
Last certification
Jul 1, 2011
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
May 27, 1992 in CA
Enrollment address
510 Cypress St
Ste D
Fort Bragg, CA 95437-5411

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
Mendocino Coast Clinics Inc6 organizations share this tax ID, including this one
Part of
Mendocino Coast Clinics Inc

Other organizations with this tax ID 5

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
Judith P Waterman Individual Corporate DirectorChief Finance Officer Jul 1, 1999
Lucresha Renteria Individual Corporate OfficerCeo Mar 4, 2016
W-2 Managing EmployeeCeo Mar 4, 2016
Susan J Peakall Individual Corporate DirectorBoard of Director Mar 29, 2019
Clare Bercot Zwerling Individual Corporate DirectorBoard of Director Mar 12, 2019
Trevor J. Orchard Individual Corporate DirectorVice Chairman Jul 9, 2019
Kelly Grimes Individual Corporate DirectorChairman Oct 26, 2016
Daphne Haney Individual Corporate DirectorTreasurer Jun 9, 2015
Claudia Boudreau Individual Corporate DirectorSecretary Nov 23, 2004
Chris Knoerdel Individual Corporate DirectorDirector Aug 15, 2016
Rio Parfrey Individual Corporate OfficerSecretary Mar 12, 2019
Araceli Rivas Individual Corporate DirectorBoard of Director May 14, 2019
Yadira Sanchez Individual Corporate DirectorBoard of Director Jul 11, 2019
Michelle a Gordon Individual Corporate OfficerFinance Officer Administration Aug 29, 2016
Christine Kelly Individual Corporate DirectorBoard of Director Mar 29, 2019

NPI Registry JSON

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

{
    "created_epoch": "1310083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1572220800000",
    "number": "1326335464",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 SOUTH ST",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "954375540",
            "telephone_number": "707-964-1251",
            "fax_number": "707-961-2653"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "510 CYPRESS ST STE D",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "95437",
            "telephone_number": "707-964-5696"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COAST CLINICS, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MENDOCINO COAST CLINICS, INC",
        "enumeration_date": "2011-07-08",
        "last_updated": "2019-10-28",
        "status": "A",
        "authorized_official_last_name": "RENTERIA",
        "authorized_official_first_name": "LUCRESHIA",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "707-964-1251"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Bragg, CA

Sources for this page

Verify at the official NPI Registry.