NPIMap

Organization Active NPI

Mendocino Coast Clinics Inc

  • Federally Qualified Health Center (FQHC)
  • Fort Bragg, CA
National Provider Identifier
1689336984
Registry record updated Oct 13, 2021
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
208 Dana St
Fort Bragg, CA 95437-4501
Phone
(707) 964-1251
NPI assigned
Oct 13, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 13, 2021

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

208 Dana St
Fort Bragg, CA 95437-4501

Mailing address

205 South St
Fort Bragg, CA 95437-5540
Phone (707) 964-1251

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230628001271 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 1689336984. Details of each certification follow.

Federally qualified health center certification: CCN A01166

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
208 Dana St
Fort Bragg, CA 95437-4501

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
Mendocino Coast Clinics Inc6 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

208 Dana St
Fort Bragg, CA 95437
Phone (707) 964-1251

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 Jan 1, 2016 100%
W-2 Managing Employee Jul 1, 1994
Other Oct 31, 2003
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 DirectorTreasurer 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 Jul 11, 2019
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.

NPI Registry JSON

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

{
    "created_epoch": "1634083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634083200000",
    "number": "1689336984",
    "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": "707-964-1251"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "208 DANA ST",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "954374501",
            "telephone_number": "707-964-1251"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COAST CLINICS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-13",
        "last_updated": "2021-10-13",
        "certification_date": "2021-09-29",
        "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.