Borrego Community Health Foundation

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

BORREGO COMMUNITY HEALTH FOUNDATION

Doing business as

Lake Elsinore Clinica Medica Familiar

Practice address

31739 Riverside Dr Ste A1
Lake Elsinore, CA 92530-7818

Phone

(619) 873-3538

NPI assigned

Apr 30, 2019

Last updated

Apr 30, 2019By the provider in NPPES

Organization subpart

Yes

Parent organization

BORREGO COMMUNITY HEALTH FOUNDATIONAs reported in NPPES

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

Authorized official

Name

Mikia Brayton Wallis

Title

Ceo

Phone

(760) 767-6641

Specialties & licenses 1

Addresses

Other names 1

• LAKE ELSINORE CLINICA MEDICA FAMILIAR Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558925016. Details of each certification follow.

• CCN 921151 Federally qualified health center · Active · Name & address match · Details

Federally qualified health center certification: CCN 921151

Legal name

LAKE ELSINORE CLINICA MEDICA FAMILIAR

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

May 9, 2019

Last certification

May 9, 2019

Ownership / control type

For profit – corporation

Facility address

31739 Riverside Dr
Lake Elsinore, CA 92530

Part of

Borrego Community Health

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

{
    "created_epoch": "1556582400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556582400000",
    "number": "1558925016",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2369",
            "city": "BORREGO SPRINGS",
            "state": "CA",
            "postal_code": "920042369",
            "telephone_number": "619-873-3538"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "31739 RIVERSIDE DR STE A1",
            "city": "LAKE ELSINORE",
            "state": "CA",
            "postal_code": "925307818",
            "telephone_number": "619-873-3538"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BORREGO COMMUNITY HEALTH FOUNDATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BORREGO COMMUNITY HEALTH FOUNDATION",
        "enumeration_date": "2019-04-30",
        "last_updated": "2019-04-30",
        "status": "A",
        "authorized_official_last_name": "WALLIS",
        "authorized_official_first_name": "MIKIA",
        "authorized_official_middle_name": "BRAYTON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "760-767-6641"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LAKE ELSINORE CLINICA MEDICA FAMILIAR",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Addie Birdsell, BA
• Amy Leigh Blickhahn, RN, BSN
• Blue Skies Physical Therapy
• Gregory William Bocash, DMD
• Dulce R Bonilla, BA
• Skyler Devin Boze
• Michael Charles Bracamontes, DPT
• Alyssa R Bradley
• Jordan Pitcher Brand, DC
• Erin Michelle Braun, MSW

• Federally Qualified Health Center (FQHC) in Lake Elsinore, CA
• Providers in Lake Elsinore, CA by specialty
• Federally Qualified Health Center (FQHC) in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.