NPIMap

Organization Active NPI

Mendocino Community Health Clinic, Inc.

Doing business as Dora Street Health Center

  • Federally Qualified Health Center (FQHC)
  • Ukiah, CA
National Provider Identifier
1356714646
Registry record updated Nov 20, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Doing business as
Dora Street Health Center
Practice address
1165 S Dora St, Suite A1
Ukiah, CA 95482-8325
Phone
(707) 468-1010
NPI assigned
Nov 9, 2015
Last updated
Nov 20, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 20, 2015

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

Authorized official

Name
Mrs. Carole Press
Title
C.E.O.
Phone
(707) 468-1010

Specialties & licenses 1

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

Addresses

Primary practice location

1165 S Dora St, Suite A1
Ukiah, CA 95482-8325

Mailing address

333 Laws Ave
Ukiah, CA 95482-6540
Phone (707) 468-1010

Other names 1

  • Dora Street Health Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040826001483 CA Part B Supplier - Clinic/Group Practice 6305755455 Receives reassigned benefits from 135 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lakeport, CA; Ukiah, CA; Willits, CA
O20181031001331 CA Part A Provider - Federally Qualified Health Center (FQHC) 6305755455 Practice locations: Ukiah, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356714646. Details of each certification follow.

Federally qualified health center certification: CCN 921101

Legal name
MENDOCINO COMMUNITY HEALTH CLINIC INC
Doing business as
DORA STREET HEALTH CENTER SUTE A1
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 27, 2018
Last certification
Nov 27, 2018
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Mar 2, 1992 in CA
Enrollment address
1165 S Dora St
Ste A1
Ukiah, CA 95482-6353

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory

Locations

1165 S Dora St
Ste A1
Ukiah, CA 95482
Phone (707) 468-1010

45 Hazel St
Willits, CA 95490
Phone (707) 456-9600

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Lavonna Schrock Individual Corporate OfficerCfo Nov 10, 2014
W-2 Managing EmployeeCfo Nov 12, 2014
Victoria Kelly Individual Corporate DirectorBoard Member Dec 1, 2021
Gary Wakeman Individual Corporate DirectorBoard Member Mar 1, 2024
Carlos Frausto Individual Corporate DirectorBRD MBR Dec 1, 2000
Martha Barra Individual Corporate DirectorBoard Member Mar 1, 2024
Daniel McIntire Individual Corporate DirectorBoard Member Mar 1, 2024
Rodney Grainger Individual Corporate OfficerCeo Aug 2, 2021
Carre Brown Individual Corporate DirectorBoard Member Mar 1, 2021
Jackeline Gonzalez de Orozco Individual Corporate DirectorBoard Member - Vice Chair Jan 1, 2021
Stephen Miller Individual Corporate DirectorBoard Member Sep 1, 2023
Pam Carr Individual W-2 Managing EmployeeBilling Manager Dec 13, 1968
John Pavoni Individual Corporate DirectorBoard Member - Chair Sep 1, 2012

Practitioners & affiliated clinicians

Practitioners 130

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 130

NPI Registry JSON

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

{
    "created_epoch": "1447027200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447977600000",
    "number": "1356714646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "333 LAWS AVE",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954826540",
            "telephone_number": "707-468-1010",
            "fax_number": "707-468-0793"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1165 S DORA ST, SUITE A1",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954828325",
            "telephone_number": "707-468-1010"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COMMUNITY HEALTH CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-09",
        "last_updated": "2015-11-20",
        "status": "A",
        "authorized_official_last_name": "PRESS",
        "authorized_official_first_name": "CAROLE",
        "authorized_official_title_or_position": "C.E.O.",
        "authorized_official_telephone_number": "707-468-1010",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dora Street Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ukiah, CA

Sources for this page

Verify at the official NPI Registry.