NPIMap

Organization Active NPI

Venice Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Redondo Beach, CA
National Provider Identifier
1356914857
Registry record updated Nov 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
VENICE FAMILY CLINIC
Practice address
2114 Artesia Blvd
Redondo Beach, CA 90278-3014
Phone
(310) 802-6177
Fax
(310) 802-6178
NPI assigned
Jul 21, 2021
Last updated
Nov 30, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
VENICE FAMILY CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 30, 2023

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

Authorized official

Name
Dr. Mitesh G Popat, MDNPI 1104057397
Title
Chief Executive Officer
Phone
(310) 664-7901

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

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

Addresses

Primary practice location

2114 Artesia Blvd
Redondo Beach, CA 90278-3014

Mailing address

604 Rose Ave
Venice, CA 90291-2767
Phone (310) 392-8636

Other names 1

  • Venice South Bay Redondo Beach Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211122001779 CA Part A Provider - Federally Qualified Health Center (FQHC) 2264339126 Practice locations: Redondo Beach, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356914857. Details of each certification follow.

Federally qualified health center certification: CCN 551960

Legal name
VENICE FAMILY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 6, 2004
Last certification
Mar 6, 2004
Ownership / control type
For profit – partnership
Most recent change of ownership
Nov 1, 2021 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Mar 27, 1974 in CA
Enrollment address
2114 Artesia Blvd
Redondo Beach, CA 90278-3014

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0548498Venice South Bay Redondo Beach2114 Artesia Blvd, Redondo Beach, CA 90278Provider-performed microscopyMar 14, 2027

National Provider Directory

National Provider Directory
Tax ID family
Venice Family - Store 234 organizations share this tax ID, including this one
Part of
Venice Family - Store 2

Other organizations with this tax ID 33

Organizations that report the same tax identification number in the National Provider Directory.

View all 33

Ownership & related parties

All disclosed owners & managing parties 22

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

NameRoleSinceShare
Joan Herman Individual Corporate DirectorBoard Chair Jul 1, 2020
Michael St Pierre Individual Corporate DirectorBoard Member Jul 1, 2021
Nadia Shaheen Individual Corporate DirectorBoard Member Jul 1, 2021
Taryn a Keane Individual Corporate DirectorBoard Member Jul 1, 2020
Jeffrey E Sinaiko Individual Corporate DirectorTreasurer Jul 1, 2021
Patricia Ramirez Individual Corporate DirectorBoard Member Jul 1, 2020
John Geresi Individual Corporate DirectorImmediate Past Chair Jul 1, 2021
Carolina Monge Individual Corporate DirectorBehavioral Health Committee Chair Jul 1, 2020
Neil H Parker Individual Corporate DirectorParliamentarian Jul 1, 2021
Kenrick Bascom Individual Corporate DirectorBoard Member Jul 1, 2020
Susan Fleischman Individual Corporate DirectorBoard Member Jul 1, 2021
Andrea Blackbird Individual Corporate OfficerCfo Mar 3, 2014
Allan E Gordon Individual Corporate DirectorPublic Policy Committee Chair Jul 1, 2021
Mark R Gavens Individual Corporate DirectorAudit Committee Chair Jul 1, 2021
Michele L Delmonico Individual Corporate DirectorBoard Member Jul 1, 2021
Olga Carrasco Individual Corporate DirectorBoard Member Jul 1, 2021
William Flumenbaum Individual Corporate DirectorStrategic Planning Committee Chair Jul 1, 2020
Mayer B Davidson Individual Corporate DirectorFounder Jul 1, 2020
Theresa M Arce Individual W-2 Managing EmployeeDirector of Revenue Cycle Jul 11, 2011
Mitesh Popat Individual Corporate OfficerCeo Dec 12, 2022
W-2 Managing EmployeeCeo Dec 12, 2022
Diana Carsola Individual Corporate DirectorBoard Member Jul 1, 2021
Sharon L Gelfand Individual Corporate DirectorBoard Member Jul 1, 2021

Owners & managing parties with NPI records 2

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Venice Family Clinic-Bills Clinic at Safe Place for YouthVenice, CA, CCN 751948 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family Clinic-Santa Monica High SchoolSanta Monica, CA, CCN 751960 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family ClinicCarson, CA, CCN 751055 Federally qualified health center 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Oct 1, 2021
Oct 1, 2021
Venice Family Clinic - Sandy Segal Youth Health CenterCulver City, CA, CCN A01923 Federally qualified health center Operational/Managerial Control Feb 1, 2017

Owned or controlled facilities with NPI records 4

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

Change-of-ownership history 1

DateEventCounterparty
Nov 1, 2021 Change of OwnershipThis provider was the buyer South Bay Family Healthcare CenterCCN 551960, CA, NPI 1548301229

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Practitioners 1

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": "1626825600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701302400000",
    "number": "1356914857",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "604 ROSE AVE",
            "city": "VENICE",
            "state": "CA",
            "postal_code": "902912767",
            "telephone_number": "310-392-8636"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2114 ARTESIA BLVD",
            "city": "REDONDO BEACH",
            "state": "CA",
            "postal_code": "902783014",
            "telephone_number": "310-802-6177",
            "fax_number": "310-802-6178"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VENICE FAMILY CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "VENICE FAMILY CLINIC",
        "enumeration_date": "2021-07-21",
        "last_updated": "2023-11-30",
        "certification_date": "2023-11-30",
        "status": "A",
        "authorized_official_last_name": "POPAT",
        "authorized_official_first_name": "MITESH",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "310-664-7901",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Venice South Bay Redondo Beach",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Redondo Beach, CA

Sources for this page

Verify at the official NPI Registry.