NPIMap

Organization Active NPI

Mendocino Community Health Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Lakeport, CA
National Provider Identifier
1770516304
Registry record updated May 3, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Practice address
5335 Lakeshore Blvd
Lakeport, CA 95453-6123
Phone
(707) 263-7725
NPI assigned
Jul 8, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 3, 2019

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

Authorized official

Name
Mr. Tim Dolan
Title
Cfo
Phone
(707) 467-2260

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 110000350 CA
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

5335 Lakeshore Blvd
Lakeport, CA 95453-6123

Mailing address

333 Laws Ave
Ukiah, CA 95482-6540
Phone (707) 468-1010

Other identifiers 2

IdentifierTypeStateIssuer
HAP70845FOtherCAFAMILYPACT
FHC70845FMedicaidCA

Other names 1

  • Lakeside Health Center Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100616000495 CA Part A Provider - Federally Qualified Health Center (FQHC) 6305755455 1 other NPI on this enrollment
Practice locations: Lakeport, CA

Federally qualified health center certification: CCN 551893

Legal name
MENDOCINO COMMUNITY HEALTH CLINIC INC
Doing business as
MENDOCINO COMMUNITY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 15, 2001
Last certification
Nov 15, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 2, 1991 in CA
Enrollment address
5335 Lakeshore Blvd
Lakeport, CA 95453-6123

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Carlos Frausto Individual Corporate Director Jun 1, 2009
Kelly E Sanford Individual Corporate Officer Feb 2, 2026
W-2 Managing Employee Feb 2, 2026
Operational/Managerial Control Feb 2, 2026
John Pavoni Individual Corporate Director Jun 1, 2009

Practitioners & affiliated clinicians

Practitioners 57

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 57

NPI Registry JSON

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

{
    "created_epoch": "1152316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556841600000",
    "number": "1770516304",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "333 LAWS AVE",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954826540",
            "telephone_number": "707-468-1010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5335 LAKESHORE BLVD",
            "city": "LAKEPORT",
            "state": "CA",
            "postal_code": "954536123",
            "telephone_number": "707-263-7725"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COMMUNITY HEALTH CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-08",
        "last_updated": "2019-05-03",
        "status": "A",
        "authorized_official_last_name": "DOLAN",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "707-467-2260",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "CA",
            "license": "110000350",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FAMILYPACT",
            "identifier": "HAP70845F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70845F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeside Health Center",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Lakeside Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Lakeport, CA

Sources for this page

Verify at the official NPI Registry.