NPIMap

Organization Active NPI

Venice Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Santa Monica, CA
National Provider Identifier
1679016463
Registry record updated Sep 11, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
VENICE FAMILY CLINIC
Practice address
601 Pico Blvd
Santa Monica, CA 90405-1224
Phone
(310) 392-8636
NPI assigned
Nov 28, 2016
Last updated
Sep 11, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
VENICE FAMILY CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 11, 2023

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

Authorized official

Name
Dr. Mitesh G Popat, MDNPI 1104057397
Title
Chief Executive Officer
Phone
(310) 664-7901

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

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

Addresses

Primary practice location

601 Pico Blvd
Santa Monica, CA 90405-1224

Mailing address

604 Rose Ave
Venice, CA 90291-2767
Phone (310) 392-8636

Other names 1

  • SAMO HI Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170126000278 CA Part A Provider - Federally Qualified Health Center (FQHC) 2264339126 Practice locations: Santa Monica, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679016463. Details of each certification follow.

Federally qualified health center certification: CCN 751960

Legal name
VENICE FAMILY CLINIC
Doing business as
VENICE FAMILY CLINIC-SANTA MONICA HIGH SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 20, 2017
Last certification
Apr 20, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 31, 1973 in CA
Enrollment address
601 Pico Blvd
Santa Monica, CA 90405-1224

Other NPIs with the same Medicare PAC ID 16

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

View all 16

National Provider Directory

National Provider Directory
Tax ID family
Venice Family Clinic34 organizations share this tax ID, including this one
Part of
Venice Family Clinic

Other organizations with this tax ID 33

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

View all 33

Locations

601 Pico Blvd
Santa Monica, CA 90405
Phone (310) 395-3204

Ownership & related parties

All disclosed owners & managing parties 24

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

NameRoleSinceShare
Joan Herman Individual Corporate DirectorBoard Chair Jul 1, 2021
Joanne Bourne Individual Corporate DirectorBoard Member Jun 1, 2022
Michael St Pierre Individual Corporate DirectorBoard Member Jul 1, 2016
Taryn a Keane Individual Corporate DirectorBoard Member Jul 1, 2021
Jeffrey E Sinaiko Individual Corporate DirectorBoard Member Jul 1, 2015
Yesenia Gallegos Individual Corporate DirectorBoard Member Jun 1, 2020
John Geresi Individual Corporate DirectorChair, Resource Development Comm Jul 26, 2016
Venice Family Clinic Organization, Venice, CA Non-profit 5% Or Greater Direct Ownership Interest Mar 27, 1974 100%
Joy Higa Individual Corporate DirectorBoard Member Aug 1, 2023
Jennifer Campos Individual Corporate DirectorBoard Member Jun 15, 2024
Carolina Monge Individual Corporate DirectorBoard Member Jul 1, 2021
Kenrick Bascom Individual Corporate DirectorBoard Member Jul 1, 2021
Susan Fleischman Individual Corporate DirectorBoard Member Jul 1, 2021
Matthew James Kinney Individual Corporate DirectorBoard Member Aug 1, 2023
Isabela Mihai Individual Corporate OfficerCco Oct 14, 2024
Operational/Managerial ControlCco Oct 14, 2024
Hilda Pena Individual Corporate DirectorBoard Member Apr 1, 2023
Sergio D Bautista Individual Corporate OfficerCfo Sep 15, 2025
Mark R Gavens Individual Corporate DirectorAudit Committee Chair Jul 1, 2021
Michele L Delmonico Individual Corporate DirectorBoard Member Jul 1, 2021
Olga Carrasco Individual Corporate DirectorBoard Member Jul 1, 2016
Mayer B Davidson Individual Corporate DirectorCo-Founder; Board Member; Chair, Jul 1, 2015
Mitesh Popat Individual Corporate OfficerCeo Dec 12, 2022
W-2 Managing Employee Dec 12, 2022
Diana Carsola Individual Corporate DirectorBoard Member Jul 1, 2016
Sharon L Gelfand Individual Corporate Director Jul 1, 2021

Owners & managing parties with NPI records 17

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

View all 17

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Venice Family Clinic-Bills Clinic at Safe Place for YouthVenice, CA, CCN 751948 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 27, 1974
Venice Family ClinicCarson, CA, CCN 751055 Federally qualified health center 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Oct 1, 2021
Oct 1, 2021
Venice Family Clinic - Sandy Segal Youth Health CenterCulver City, CA, CCN A01923 Federally qualified health center Operational/Managerial Control Feb 1, 2017

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1480291200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694390400000",
    "number": "1679016463",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "604 ROSE AVE",
            "city": "VENICE",
            "state": "CA",
            "postal_code": "902912767",
            "telephone_number": "310-392-8636"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "601 PICO BLVD",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904051224",
            "telephone_number": "310-392-8636"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VENICE FAMILY CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "VENICE FAMILY CLINIC",
        "enumeration_date": "2016-11-28",
        "last_updated": "2023-09-11",
        "certification_date": "2023-09-11",
        "status": "A",
        "authorized_official_last_name": "POPAT",
        "authorized_official_first_name": "MITESH",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "310-664-7901",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "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": "SAMO HI",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Santa Monica, CA

Sources for this page

Verify at the official NPI Registry.