NPIMap

Organization Active NPI

East Valley Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • La Puente, CA
National Provider Identifier
1386912202
Registry record updated Feb 11, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
550002062 Issued in CA
Legal business name
EAST VALLEY COMMUNITY HEALTH CENTER, INC.
Practice address
17840 Villa Corta St
La Puente, CA 91744-5342
Phone
(626) 919-4333
Fax
(626) 919-2084
NPI assigned
Dec 6, 2011
Last updated
Feb 11, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2022

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

Authorized official

Name
Ms. Alicia Mardini
Title
Chief Executive Officer
Phone
(626) 919-4333

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550002062 CA Primary
Case Manager/Care Coordinator 171M00000X NU

Addresses

Primary practice location

17840 Villa Corta St
La Puente, CA 91744-5342

Mailing address

420 S Glendora Ave
West Covina, CA 91790-3001
Phone (626) 919-4333

Other identifiers 2

IdentifierTypeStateIssuer
FHC12048FMedicaidCA
550002062OtherCACA DEPARTMENT OF PUBLIC HEALTH LICENSE

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130123000181 CA Part A Provider - Federally Qualified Health Center (FQHC) 9234041765 Practice locations: La Puente, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386912202. Details of each certification follow.

Federally qualified health center certification: CCN 551199

Legal name
EAST VALLEY COMMUNITY HEALTH CENTER, INC.
Doing business as
EAST VALLEY COMMUNITY HEALTH CENTER/VILLACORTA SCHOOL CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 23, 2013
Last certification
Jan 23, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 16, 1970 in CA
Enrollment address
17840 Villa Corta St
La Puente, CA 91744-5342

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
East Valley Community Health Center Inc16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

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

View all 15

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
Priscilla Stroud Individual Corporate DirectorBoard Member Aug 31, 2016
Elisa Jimenez Individual Corporate DirectorBoard Member Sep 1, 2018
Doran Barnes Individual Corporate DirectorBoard Memner Sep 1, 2003
Thomas D Allison Individual Corporate DirectorBoard Memeber Apr 25, 2012
Tony Song Individual Corporate DirectorBoard Member Dec 15, 2005
Chinhnam Hathuc Individual Corporate OfficerChief Medical Officer Jul 1, 2014
W-2 Managing EmployeeChief Medical Officer Jul 1, 2014
Areceli Lopez Individual Corporate DirectorBoard Member Sep 1, 2017
Alicia Mardini Individual Corporate OfficerChief Executive Officer Jul 1, 1983 100%
W-2 Managing EmployeeChief Executive Officer Nov 1, 2012
Robert Beam Individual Corporate DirectorBoard Member Jun 25, 2014
Chalikorn M Chan Individual Corporate DirectorBoard Member Aug 1, 2018
Gorpat Charoen Individual Corporate OfficerChief Operating Officer Sep 13, 2021
W-2 Managing EmployeeChief Operating Officer Sep 13, 2021

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1323129600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644537600000",
    "number": "1386912202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 S GLENDORA AVE",
            "city": "WEST COVINA",
            "state": "CA",
            "postal_code": "917903001",
            "telephone_number": "626-919-4333",
            "fax_number": "626-919-2084"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17840 VILLA CORTA ST",
            "city": "LA PUENTE",
            "state": "CA",
            "postal_code": "917445342",
            "telephone_number": "626-919-4333",
            "fax_number": "626-919-2084"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST VALLEY COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-12-06",
        "last_updated": "2022-02-11",
        "certification_date": "2022-02-11",
        "status": "A",
        "authorized_official_last_name": "MARDINI",
        "authorized_official_first_name": "ALICIA",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "626-919-4333",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "550002062",
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC12048F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CA DEPARTMENT OF PUBLIC HEALTH LICENSE",
            "identifier": "550002062",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in La Puente, CA

Sources for this page

Verify at the official NPI Registry.