Tri-State Community Healthcare Center
Organization Active NPI Federally Qualified Health Center (FQHC) · Adelanto, CA
NPI 1508379017 · NPPES record last updated Sep 29, 2025
Key facts
- NPI
- 1508379017
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- TRI-STATE COMMUNITY HEALTHCARE CENTER
- Practice address
- 11499 Bartlett Ave
Adelanto, CA 92301-1902 - Phone
- (760) 444-4258
- NPI assigned
- Nov 7, 2017
- Organization subpart
- Yes
- Parent organization (as reported)
- TRI-STATE COMMUNITY HEALTHCARE CENTER
Authorized official
- Name
- Crystale Mineros
- Title
- Credentialing Manager
- Phone
- (909) 575-7161
Parent organization (reported in NPPES) 1
Owners & managing parties with NPI records 3
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 3
Facilities with the same owner 2
Practitioners 51
-
Natalie Rae Goodermont, RN, MSN, FNP
-
Shahram S. Mirhashemi, M.D.
-
Judith L Trevisano, AGNP
-
Mark A Folmsbee, D.O.
-
Arthur Sarkisian, LCSW, PSY.D. CANDIDA
-
Ebram Abdelmalak, DPM
-
Parviz Akhavan, D.O
-
Adamma Theresa Amadi, FNP
-
Arra Apikian, OD
-
Kathy Le Ballek, PMHNP-BC
-
Hind Bennani, DPM
-
Zubeida Hassen Birhan, P.A.
-
Kenrick Carlyle Bourne, PA-C
-
Maria Cristina Enriquez, FNP-BC
-
Joseph Christian Fernandez, MSN, RN, FNP-BC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D2271454 | Tri-State Community Healthcare Center | Certificate of waiver | Nov 1, 2026 |
| 05D2273167 | Tri-State Community Healthcare Center | Certificate of waiver | Dec 6, 2026 |
| 05D2285000 | Tri-State Community Healthcare Center | Certificate of waiver | Jul 2, 2027 |
| 05D2316911 | Tri-State Community Healthcare Center | Certificate of waiver | Jan 13, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA
Federally qualified health center certification: CCN 921090
- Legal name
- TRI-STATE COMMUNITY HEALTHCARE CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- May 21, 2018
- Last certification
- May 21, 2018
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 1, 2012 in CA
- Enrollment address
- 11499 Bartlett Ave
Adelanto, CA 92301-1902
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| George Deleon |
Corporate Director |
Dec 14, 2015 | |
| Jeffrey Williams |
Corporate Director |
Jan 10, 2011 | |
| John Pazirandeh |
Corporate Officer |
Oct 1, 2016 | |
| Kellie a McKenzie |
Corporate Director |
Sep 11, 2017 | |
| Mark Hannawi |
Corporate Director |
Nov 20, 2015 | |
| Betty E Starr |
Corporate Director |
Dec 14, 2015 | |
| Pamela Jean J Blake |
Corporate Director |
Mar 9, 2015 | |
| Tri-State Community Healthcare Center |
Operational/Managerial Control | Mar 1, 2016 | 100% |
| Barry Solomon |
Corporate Director |
Oct 14, 2021 | |
| Armenak Takhmizyan |
Corporate Director |
Nov 2, 2022 | |
| Maria a Sotnikova |
Corporate Officer |
Jun 22, 2016 | |
| W-2 Managing Employee |
Jun 22, 2016 | ||
| Mary Lou Stein |
Corporate Director |
Mar 14, 2016 | |
| Nancy L Nelson |
Corporate Director |
Sep 11, 2017 | |
| Aram Manoukian |
Corporate Officer |
Jun 7, 2012 | |
| W-2 Managing Employee |
Jun 7, 2012 |
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| Tri-State Community Healthcare Center |
Federally qualified health center | Operational/Managerial Control | May 1, 2015 |
| Tri-State Community Healthcare Center |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Jul 18, 2011 |
| Tri-State Community Healthcare Center |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Jul 18, 2011 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20131114000307 | CA | Part B Supplier - Clinic/Group Practice | 5597991968 |
Receives reassigned benefits from 79 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Los Angeles, CA; San Fernando, CA; Pomona, CA; Needles, CA; Hemet, CA; Adelanto, CA |
| O20180418002336 | CA | Part a Provider - Federally Qualified Health Center (FQHC) | 5597991968 | Practice locations: Adelanto, CA |
National Provider Directory
- Part of
- Tri-State Comm Hlthcare Ctr
Locations
11499 Bartlett Ave
Adelanto, CA 92301
Phone (760) 444-4258
1535 E Colorado St
Glendale, CA 91205
540 N San Jacinto St
Ste I
Hemet, CA 92543
Phone (951) 651-1006
6630 Crenshaw Blvd
Los Angeles, CA 90043
Phone (213) 686-1517
3600 E 1st St
Los Angeles, CA 90063
Phone (323) 526-9778
1532 San Bernardino Ave
Ste B7
Pomona, CA 91767
Phone (909) 301-4041
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Primary Care Clinic/Center | 261QP2300X |
Addresses
Primary practice location
11499 Bartlett Ave
Adelanto, CA 92301-1902
Mailing address
1535 E Colorado St
Glendale, CA 91205-1513
Other practice location 1
11888 Bartlett Ave
Adelanto, CA 92301-1709
Phone (760) 530-9944
Other practice location 2
6630 Crenshaw Blvd
Los Angeles, CA 90043-4102
Phone (213) 686-1517
Other practice location 3
3600 E 1st St
Los Angeles, CA 90063-2326
Phone (323) 694-0911
Other practice location 4
540 N San Jacinto St Ste I
Hemet, CA 92543-3154
Phone (951) 651-1006
Other practice location 5
1532 San Bernardino Ave Ste A2
Pomona, CA 91767-3559
Phone (909) 301-4041
Other practice location 6
11273 Laurel Canyon Blvd Ste 2
San Fernando, CA 91340-4357
Phone (818) 853-2220
Other practice location 7
1532 San Bernardino Ave Ste B7
Pomona, CA 91767-3559
Phone (909) 301-4041
Other practice location 8
540 N San Jacinto St Ste P
Hemet, CA 92543-3154
Phone (951) 929-4000
Other practice location 9
4137 Verdugo Rd
Los Angeles, CA 90065-3820
Phone (323) 344-9255
Other providers in Adelanto, CA
- The Universal of Science and Peace
- Russhya Thomas
- Berenice Torres Garcia
- Elizabeth Torres
- Tri-State Community Healthcare Center
- Tri-State Community Healthcare Center
- Brandy Nicole Trimble
- Karen Villalobos
- Edna M Washington
- Christine Louise Watson
All providers in Adelanto, CA · Federally Qualified Health Center (FQHC) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 29, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.