NPIMap

Organization Active NPI

Mission City Community Network Inc

  • Community Health Clinic/Center
  • Los Angeles, CA
National Provider Identifier
1407500374
Registry record updated Jul 22, 2022
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
Mission City Community Network, Inc
3660 Wilshire Blvd, Suite 102,
Los Angeles, CA 90010-2763
Phone
(818) 895-3100
Fax
(818) 830-0811
NPI assigned
Feb 9, 2022
Last updated
Jul 22, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2022

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

Mission City Community Network, Inc
3660 Wilshire Blvd, Suite 102,
Los Angeles, CA 90010-2763

Mailing address

Mission City Community Network Inc.
3660 Wilshire Blvd, Suite 102,
Los Angeles, CA 90010-2763
Phone (818) 895-3100

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221123000721 CA Part A Provider - Federally Qualified Health Center (FQHC) 1658264684 Practice locations: Los Angeles, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407500374. Details of each certification follow.

Federally qualified health center certification: CCN A01125

Legal name
MISSION CITY COMMUNITY NETWORK, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 15, 2022
Last certification
Nov 15, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 26, 1988 in CA
Enrollment address
3660 Wilshire Blvd
Ste 102
Los Angeles, CA 90010-2716

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
05D2315361Mission City Community Network Inc - Wilshire3660 Wilshire Blvd Suite 102, Los Angeles, CA 90010Certificate of waiverDec 10, 2026

National Provider Directory

National Provider Directory

Locations

3660 Wilshire Blvd
Ste 102
Los Angeles, CA 90010
Phone (213) 386-8866

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Nik Gupta Individual Corporate OfficerCeo Mar 16, 2001
W-2 Managing EmployeeCeo Jul 1, 2009
Frank Gonzales Individual Corporate OfficerBoard Member Jun 13, 2017
Derek Biesheuvel Individual Corporate OfficerBoard Member Mar 17, 2014

NPI Registry JSON

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

{
    "created_epoch": "1644364800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658448000000",
    "number": "1407500374",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "MISSION CITY COMMUNITY NETWORK INC.",
            "address_2": "3660 WILSHIRE BLVD, SUITE 102,",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900102763",
            "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": "MISSION CITY COMMUNITY NETWORK, INC",
            "address_2": "3660 WILSHIRE BLVD, SUITE 102,",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900102763",
            "telephone_number": "818-895-3100",
            "fax_number": "818-830-0811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSION CITY COMMUNITY NETWORK INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-09",
        "last_updated": "2022-07-22",
        "certification_date": "2022-07-22",
        "status": "A",
        "authorized_official_last_name": "GUPTA",
        "authorized_official_first_name": "NIK",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "818-895-3100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Los Angeles, CA

Sources for this page

Verify at the official NPI Registry.