NPIMap

Organization Active NPI

Venice Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Los Angeles, CA
National Provider Identifier
1790156917
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
4700 Inglewood Blvd
Suite # 101
Los Angeles, CA 90230-5896
Phone
(310) 392-8636
Fax
(310) 664-7913
NPI assigned
Oct 14, 2015
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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Case Manager/Care Coordinator 171M00000X

Addresses

Primary practice location

4700 Inglewood Blvd
Suite # 101
Los Angeles, CA 90230-5896

Mailing address

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

Other names 1

  • Lou Colen Health & Wellness Center Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170406000654 CA Part A Provider - Federally Qualified Health Center (FQHC) 2264339126 Practice locations: Culver City, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790156917. Details of each certification follow.

Federally qualified health center certification: CCN 751955

Legal name
VENICE FAMILY CLINIC
Doing business as
VENICE FAMILY CLINIC-LOU COLEN CHILDRENS HEALTH AND WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 27, 2017
Last certification
Feb 27, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 31, 1973 in CA
Enrollment address
4700 Inglewood Blvd
Ste 101
Culver City, CA 90230-5896

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D2132228Lou Colen Children's Health & Wellness Center4700 Inglewood Blvd Ste 101, Culver City, CA 90230Certificate of waiverJun 13, 2027

National Provider Directory

National Provider Directory
Part of
Venice Family - Store 3

Locations

4700 Inglewood Blvd
Ste 101
Los Angeles, CA 90230

Ownership & related parties

All disclosed owners & managing parties 22

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 Treasurer Jun 1, 2019
Joanne Bourne Individual Corporate DirectorBoard Member Jun 1, 2022
Michael St Pierre Individual Corporate DirectorBoard Member Jul 1, 2016
Nadia Shaheen Individual Corporate DirectorBoard Member Jul 1, 2015
Taryn a Keane Individual Corporate DirectorBoard Member Jul 1, 2019
Jeffrey E Sinaiko Individual Corporate DirectorBoard Chair Jul 1, 2015
Yesenia Gallegos Individual Corporate DirectorBoard Member Jun 1, 2020
John Geresi Individual Corporate DirectorBoard Member Jul 26, 2016
Joy Higa Individual Corporate DirectorBoard Member Aug 1, 2023
Carolina Monge Individual Corporate DirectorBoard Member Oct 1, 2017
Kenrick Bascom Individual Corporate DirectorBoard Member Apr 1, 2017
Susan Fleischman Individual Corporate DirectorBoard Vice Chair Jun 1, 2020
Matthew James Kinney Individual Corporate DirectorBoard Member Aug 1, 2023
Hilda Pena Individual Corporate DirectorBoard Member Apr 1, 2023
Andrea Blackbird Individual Corporate OfficerChief Financial Officer Mar 3, 2014
W-2 Managing EmployeeChief Financial Officer Mar 3, 2014
Mark R Gavens Individual Corporate DirectorBoard Chair Jun 1, 2020
Michele L Delmonico Individual Corporate DirectorBoard Member Jun 1, 2020
Olga Carrasco Individual Corporate DirectorBoard Member Jul 1, 2016
Mayer B Davidson Individual Corporate DirectorBoard Member Jul 1, 2015
Mitesh Popat Individual Corporate OfficerChief Executive Officer Dec 12, 2022
W-2 Managing EmployeeChief Executive Officer Dec 12, 2022
Diana Carsola Individual Corporate DirectorBoard Member Jul 1, 2016
Sharon L Gelfand Individual Corporate DirectorBoard Member Jun 1, 2020

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 4

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 Clinic-Santa Monica High SchoolSanta Monica, CA, CCN 751960 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 4

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

Practitioners & affiliated clinicians

Practitioners 4

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": "1444780800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694390400000",
    "number": "1790156917",
    "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": "4700 INGLEWOOD BLVD",
            "address_2": "SUITE # 101",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "902305896",
            "telephone_number": "310-392-8636",
            "fax_number": "310-664-7913"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VENICE FAMILY CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "VENICE FAMILY CLINIC",
        "enumeration_date": "2015-10-14",
        "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": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lou Colen Health & Wellness Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Los Angeles, CA

Sources for this page

Verify at the official NPI Registry.