NPIMap

Organization Active NPI

Mission City Community Network, Inc

  • Community Health Clinic/Center
  • Corona, CA
National Provider Identifier
1366010209
Registry record updated Jun 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
MISSION CITY COMMUNITY NETWORK, INC
Practice address
613 S Howard St
Corona, CA 92879-2254
Phone
(818) 895-3100
Fax
(818) 830-0811
NPI assigned
Jun 16, 2021
Last updated
Jun 16, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2021

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

Authorized official

Name
Mr. Nik Gupta
Title
Ceo & President
Phone
(818) 895-3100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X Primary

Addresses

Primary practice location

613 S Howard St
Corona, CA 92879-2254

Mailing address

613 S Howard St
Corona, CA 92879-2254
Phone (818) 895-3100

Other practice location 1

644 E Regent St
Inglewood, CA 90301-1433
Phone (818) 895-3100 ext. 602

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230524003295 CA Part A Provider - Federally Qualified Health Center (FQHC) 1658264684 Practice locations: Corona, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366010209. Details of each certification follow.

Federally qualified health center certification: CCN A01173

Legal name
MISSION CITY COMMUNITY NETWORK, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 27, 2023
Last certification
Jun 27, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 6, 1989 in CA
Enrollment address
613 S Howard St
Corona, CA 92879-2254

Other NPIs with the same Medicare PAC ID 18

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

View all 18

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
05D2318025Mission City Community Network - Corona Clinic613 S Howard St, Corona, CA 92879Certificate of waiverFeb 3, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mission City Community NTWK18 organizations share this tax ID, including this one

Other organizations with this tax ID 17

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

View all 17

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Maria Chaudhry Individual Corporate DirectorBoard Member Dec 1, 2012
Nik Gupta Individual Corporate OfficerCeo Mar 16, 2001
W-2 Managing EmployeeCeo Jul 1, 2009
Frank Gonzales Individual Corporate DirectorBoard Member Jun 13, 2017
Aida Vlught Individual Corporate DirectorBoard Member Jul 1, 2000
Norma J Solis Individual Corporate DirectorBoard Member Jun 30, 2021
Sammy Riley Individual Corporate DirectorBoard Member Feb 23, 2021
Mark Berry Individual Corporate DirectorBoard Member Aug 19, 2017
Adriana Guzman Individual Corporate DirectorBoard Member Mar 17, 2014
Magdalena Almira Individual Corporate OfficerCfo Feb 20, 2007
Rosalind Scarbrough Individual Corporate DirectorBoard Member Feb 23, 2021
Derek Biesheuvel Individual Corporate DirectorBoard Member Mar 17, 2014

NPI Registry JSON

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

{
    "created_epoch": "1623801600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623801600000",
    "number": "1366010209",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "613 S HOWARD ST",
            "city": "CORONA",
            "state": "CA",
            "postal_code": "928792254",
            "telephone_number": "818-895-3100",
            "fax_number": "818-830-0811"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "613 S HOWARD ST",
            "city": "CORONA",
            "state": "CA",
            "postal_code": "928792254",
            "telephone_number": "818-895-3100",
            "fax_number": "818-830-0811"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "644 E Regent St",
            "address_purpose": "LOCATION",
            "city": "Inglewood",
            "state": "CA",
            "postal_code": "903011433",
            "country_code": "US",
            "telephone_number": "818-895-3100 x602",
            "fax_number": "818-830-0811",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MISSION CITY COMMUNITY NETWORK, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-16",
        "last_updated": "2021-06-16",
        "certification_date": "2021-06-16",
        "status": "A",
        "authorized_official_last_name": "GUPTA",
        "authorized_official_first_name": "NIK",
        "authorized_official_title_or_position": "CEO & PRESIDENT",
        "authorized_official_telephone_number": "818-895-3100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Corona, CA

Sources for this page

Verify at the official NPI Registry.