NPIMap

Organization Active NPI

Mendocino Coast Clinics Inc

  • Federally Qualified Health Center (FQHC)
  • Fort Bragg, CA
National Provider Identifier
1609595404
Registry record updated Aug 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MENDOCINO COAST CLINICS INC
Practice address
690 S Main St
Fort Bragg, CA 95437-5108
Phone
(707) 364-1251
NPI assigned
Aug 24, 2022
Last updated
Aug 24, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 24, 2022

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

Authorized official

Name
Lucresha M Renteria
Title
Ceo
Phone
(707) 964-1251

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

690 S Main St
Fort Bragg, CA 95437-5108

Mailing address

205 South St
Fort Bragg, CA 95437-5540
Phone (707) 364-1251

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050512001033 CA Part B Supplier - Clinic/Group Practice 5991619157 Receives reassigned benefits from 34 practitioners
2 other NPIs on this enrollment
Practice locations: Fort Bragg, CA
O20230628003261 CA Part A Provider - Federally Qualified Health Center (FQHC) 5991619157 Practice locations: Fort Bragg, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609595404. Details of each certification follow.

Federally qualified health center certification: CCN A01167

Legal name
MENDOCINO COAST CLINICS, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 28, 2023
Last certification
Jun 28, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 2, 1992 in CA
Enrollment address
690 S Main St
Fort Bragg, CA 95437-5108

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Mendocino Coast Pharmacy6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Locations

205 South St
Fort Bragg, CA 95437
Phone (707) 961-4088

690 S Main St
Fort Bragg, CA 95437
Phone (707) 364-1251

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Lucresha Renteria Individual Corporate OfficerCeo Oct 26, 2016 100%
W-2 Managing EmployeeCeo Jul 1, 1994
Melissa Azevedo Individual 5% Or Greater Direct Ownership InterestChair Aug 10, 2021
Corporate OfficerChair Aug 10, 2021
Matt O'Halloran Individual Corporate DirectorBoard of Directors May 10, 2022
Trevor J. Orchard Individual Corporate OfficerSecretary Jul 9, 2019
Kelly Grimes Individual Corporate OfficerVice Chair Oct 26, 2016
James Katzel Individual Corporate DirectorBoard of Directors Aug 9, 2022
Daphne Haney Individual Corporate OfficerTreasurer Jun 9, 2015
Rio Parfrey Individual Corporate DirectorBoard of Directors Mar 12, 2019
Araceli Rivas Individual Corporate DirectorBoard of Directors May 14, 2019
Deborah Wyatt Individual Corporate DirectorBoard of Directors May 10, 2022
Yadira Sanchez Individual Corporate DirectorBoard of Directors May 10, 2022
Jeremie Foley Individual Corporate OfficerDirector of Operations Jan 1, 2023

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 35

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 35

NPI Registry JSON

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

{
    "created_epoch": "1661299200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661299200000",
    "number": "1609595404",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 SOUTH ST",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "954375540",
            "telephone_number": "707-364-1251"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "690 S MAIN ST",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "954375108",
            "telephone_number": "707-364-1251"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COAST CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-08-24",
        "last_updated": "2022-08-24",
        "certification_date": "2022-08-18",
        "status": "A",
        "authorized_official_last_name": "RENTERIA",
        "authorized_official_first_name": "LUCRESHA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "707-964-1251"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Bragg, CA

Sources for this page

Verify at the official NPI Registry.