NPIMap

Organization Active NPI

Mendocino Community Health Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Ukiah, CA
National Provider Identifier
1811958952
Registry record updated May 7, 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
333 Laws Ave
Ukiah, CA 95482-6540
Phone
(707) 468-1010
Fax
(707) 468-0174
NPI assigned
Mar 29, 2006
Last updated
May 7, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 7, 2019

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

Authorized official

Name
Mrs. Antonia Delgado Vega
Title
Billing Manager
Phone
(707) 467-2260

Specialties & licenses 1

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

Addresses

Primary practice location

333 Laws Ave
Ukiah, CA 95482-6540

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
FHC03933FMedicaidCA
EAP03933FOtherCAEAPC
HAP03933FOtherCAFAMILY PACT

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040826001483 CA Part B Supplier - Clinic/Group Practice 6305755455 Receives reassigned benefits from 135 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lakeport, CA; Ukiah, CA; Willits, CA
O20091228000345 CA Part A Provider - Federally Qualified Health Center (FQHC) 6305755455 Practice locations: Ukiah, CA
O20100616000495 CA Part A Provider - Federally Qualified Health Center (FQHC) 6305755455 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lakeport, CA

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1811958952. Details of each certification follow.

Federally qualified health center certification: CCN 051897

Legal name
MENDOCINO COMMUNITY HEALTH CLINIC INC
Doing business as
HILLSIDE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 1, 1993
Last certification
Aug 1, 1993
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 2, 1992 in CA
Enrollment address
333 Laws Ave
Ukiah, CA 95482-6540

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 4

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 13

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

NameRoleSinceShare
Brenda Espinosa Individual Corporate OfficerCfo Sep 30, 2024
Victoria Kelly Individual Corporate DirectorBoard Member Dec 1, 2001
Gary Wakeman Individual Corporate DirectorBoard Member Mar 1, 2024
Carlos Frausto Individual Corporate Director Dec 1, 2000
Corporate Director Jun 1, 2009
Martha Barra Individual Corporate DirectorBoard Member Mar 1, 2024
Daniel McIntire Individual Corporate DirectorBoard Member Mar 1, 2024
Rodney Grainger Individual Corporate OfficerCeo Aug 2, 2021
Carre Brown Individual Corporate DirectorBoard Member Mar 1, 2021
Jackeline Gonzalez de Orozco Individual Corporate DirectorBoard Member Jan 1, 2021
Stephen Miller Individual Corporate DirectorBoard Member Sep 1, 2023
Pam Carr Individual W-2 Managing EmployeeBilling Manager Jun 19, 2000
John Pavoni Individual Corporate DirectorBoard Member-Chair Sep 1, 2012
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

Practitioners & affiliated clinicians

Practitioners 56

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.

View all 56

NPI Registry JSON

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

{
    "created_epoch": "1143590400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1557187200000",
    "number": "1811958952",
    "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",
            "fax_number": "707-468-0174"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "333 LAWS AVE",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954826540",
            "telephone_number": "707-468-1010",
            "fax_number": "707-468-0174"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COMMUNITY HEALTH CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-29",
        "last_updated": "2019-05-07",
        "status": "A",
        "authorized_official_last_name": "DELGADO VEGA",
        "authorized_official_first_name": "ANTONIA",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "707-467-2260",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC03933F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EAPC",
            "identifier": "EAP03933F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FAMILY PACT",
            "identifier": "HAP03933F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ukiah, CA

Sources for this page

Verify at the official NPI Registry.