NPIMap

Organization Active NPI

St. Jude Neighborhood Health Centers

Doing business as Puente A La Salud Vision Clinic

  • Health Service Clinic/Center
  • Santa Ana, CA
National Provider Identifier
1689070716
Registry record updated Aug 10, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Health Service Clinic/CenterTaxonomy code 261QH0100X
Legal business name
ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Doing business as
Puente A La Salud Vision Clinic
Practice address
280 N Sullivan St
Santa Ana, CA 92703-3416
Phone
(714) 771-8005
Fax
(714) 744-8629
NPI assigned
Nov 18, 2014
Last updated
Aug 10, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 10, 2022

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

Authorized official

Name
Timothy Jason Brown
Title
Chief Executive Officer
Phone
(208) 899-9631

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Health Service Clinic/Center 261QH0100X Primary

Addresses

Primary practice location

280 N Sullivan St
Santa Ana, CA 92703-3416

Mailing address

731 S Highland Ave
Fullerton, CA 92832-2753
Phone (714) 446-5100

Other names 1

  • Puente A La Salud Vision Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150602003048 CA Part A Provider - Federally Qualified Health Center (FQHC) 4284886789 Practice locations: Santa Ana, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1689070716. Details of each certification follow.

Federally qualified health center certification: CCN 751172

Legal name
ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 1, 2015
Last certification
May 1, 2015
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Oct 25, 2011 in CA
Enrollment address
280 N Sullivan St
Santa Ana, CA 92703-3416

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory
Tax ID family
St Jude Neighborhood Health8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Locations

363 S Main St
#204
Orange, CA 92868
Phone (714) 771-8005

280 N Sullivan St
Santa Ana, CA 92703
Phone (714) 771-8005

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Herlinda E Ramirez Machado Individual Corporate Director Mar 27, 2018
Sheri Lindholm Individual Corporate Director Jul 1, 2020
Sonia Martinez Individual Corporate Director Jun 1, 2020
Judy Wagner Individual Corporate Director Jul 1, 2020
Julieta Barraza Individual Corporate Director Jul 1, 2020
St. Jude Neighborhood Health Centers Organization, Fullerton, CA Non-profit 5% Or Greater Direct Ownership Interest May 4, 2015 100%
Daniel Estrada Individual Corporate Director May 1, 2015
Mark Jablonski Individual Corporate Director Apr 1, 2020
Gloria Dominguez Colazo Individual Corporate DirectorBoard Member Apr 1, 2013
Juan Garcia Individual Corporate Director Jun 1, 2016
Timothy Jason Brown Individual Corporate OfficerExecutive Director Oct 22, 2012
Corporate DirectorExecutive Director (Ex-Officio) Oct 22, 2012
W-2 Managing EmployeeExecutive Director Oct 22, 2012
Cecilia Bustamante-Pixa Individual Corporate Director Mar 1, 2020
Ronald R Diluigi Individual Corporate Director Jul 1, 2015
Sylvia Reyes Individual Corporate Director Mar 27, 2018
Sandra Even Individual Corporate Director Jan 1, 2015

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
St. Jude Neighborhood Health CentersFullerton, CA, CCN 751048 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 25, 2011
St. Jude Neighborhood Health CentersFullerton, CA, CCN 751143 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2015
R1 RCMOrange, CA, CCN 921100 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Aug 1, 2018
St. Mary Health Centers - AdelantoAdelanto, CA, CCN A01062 Federally qualified health center 5% Or Greater Direct Ownership Interest Aug 24, 2020
St. Mary Health Centers - AvApple Valley, CA, CCN A01063 Federally qualified health center 5% Or Greater Direct Ownership Interest Aug 24, 2020

Owned or controlled facilities with NPI records 5

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

Facilities with the same owner 5

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

NPI Registry JSON

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

{
    "created_epoch": "1416268800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660089600000",
    "number": "1689070716",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "731 S HIGHLAND AVE",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928322753",
            "telephone_number": "714-446-5100",
            "fax_number": "714-744-8629"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "280 N SULLIVAN ST",
            "city": "SANTA ANA",
            "state": "CA",
            "postal_code": "927033416",
            "telephone_number": "714-771-8005",
            "fax_number": "714-744-8629"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. JUDE NEIGHBORHOOD HEALTH CENTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-11-18",
        "last_updated": "2022-08-10",
        "certification_date": "2022-08-10",
        "status": "A",
        "authorized_official_last_name": "BROWN",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "JASON",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "208-899-9631"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Puente A La Salud Vision Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Puente A La Salud Vision Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Santa Ana, CA

Sources for this page

Verify at the official NPI Registry.