NPIMap

Organization Active NPI

Mattapan Community Health Center Inc

  • Federally Qualified Health Center (FQHC)
  • Mattapan, MA
National Provider Identifier
1639240393
Registry record updated Apr 29, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MATTAPAN COMMUNITY HEALTH CENTER INC
Practice address
1575 Blue Hill Ave
Mattapan, MA 02126-2122
Phone
(617) 296-0061
Fax
(617) 296-5408
NPI assigned
Nov 13, 2006
Last updated
Apr 29, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 29, 2019

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

Authorized official

Name
Guale Valdez
Title
President & Chief Executive Officer
Phone
(617) 898-9090

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1575 Blue Hill Ave
Mattapan, MA 02126-2122

Mailing address

1575 Blue Hill Ave
Mattapan, MA 02126-2122
Phone (617) 296-0061

Other identifiers 1

IdentifierTypeStateIssuer
1301438MedicaidMA

Other names 1

  • FQHC Facility Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130313000000 MA Part A Provider - Federally Qualified Health Center (FQHC) 2062423866 Practice locations: Mattapan, MA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639240393. Details of each certification follow.

Federally qualified health center certification: CCN 221808

Legal name
MATTAPAN COMMUNITY HEALTH CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 8, 1974 in MA
Enrollment address
1575 Blue Hill Ave
Mattapan, MA 21262122

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory
Tax ID family
FQHC Facility3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

100 S Shore Dr
Fl 2
East Haven, CT 06512

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Eno Mondesir Individual Corporate DirectorBoard Member Jul 1, 1977
Cheryl Lindsay Individual Corporate DirectorBoard Member Jul 1, 1983 100%
Thomas Hawkins Individual Corporate DirectorBoard Member Feb 1, 2014
Audrey Thomas-Miller Individual Corporate DirectorBoard Member Jan 1, 2018
Georgette Copeland Individual Corporate DirectorBoard Member Jan 1, 2019
Glenola Mitchell Individual Corporate OfficerChairperson Jul 1, 2000 100%
Guale Valdez Individual Corporate OfficerPresident & Chief Executive Officer Dec 15, 2017
Operational/Managerial ControlPresident & Chief Executive Officer Dec 15, 2017 100%
Christopher Brandon Individual Corporate DirectorBoard Member Jul 1, 1991 100%

Practitioners & affiliated clinicians

Practitioners 62

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 62

NPI Registry JSON

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

{
    "created_epoch": "1163376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556496000000",
    "number": "1639240393",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1575 BLUE HILL AVE",
            "city": "MATTAPAN",
            "state": "MA",
            "postal_code": "021262122",
            "telephone_number": "617-296-0061",
            "fax_number": "617-296-5408"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1575 BLUE HILL AVE",
            "city": "MATTAPAN",
            "state": "MA",
            "postal_code": "021262122",
            "telephone_number": "617-296-0061",
            "fax_number": "617-296-5408"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MATTAPAN COMMUNITY HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-13",
        "last_updated": "2019-04-29",
        "status": "A",
        "authorized_official_last_name": "VALDEZ",
        "authorized_official_first_name": "GUALE",
        "authorized_official_title_or_position": "PRESIDENT & CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "617-898-9090"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1301438",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FQHC Facility",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "FQHC Facility",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Mattapan, MA

Sources for this page

Verify at the official NPI Registry.