NPIMap

Organization Active NPI

South County Community Health Center Inc

  • Primary Care Clinic/Center
  • East Palo Alto, CA
National Provider Identifier
1821170044
Registry record updated Feb 1, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
SOUTH COUNTY COMMUNITY HEALTH CENTER INC
Practice address
1885 Bay Road
East Palo Alto, CA 94303-1611
Phone
(650) 330-7400
Fax
(650) 321-1560
NPI assigned
Oct 19, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 1, 2022

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

Authorized official

Name
Mr. Gralyn Jacques
Title
Cfo
Phone
(650) 330-7400

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Case Management Agency 251B00000X
Primary Care Clinic/Center 261QP2300X
Primary Care Clinic/Center 261QP2300X CA Primary

Addresses

Primary practice location

1885 Bay Road
East Palo Alto, CA 94303-1611

Mailing address

1885 Bay Road
East Palo Alto, CA 94303-1611
Phone (650) 330-7400

Other identifiers 4

IdentifierTypeStateIssuer
BCP70935FOtherCACANCER DETECTION PROGRAM
HAP70935FOtherCAFAMILY PACT
EAP70935FOtherCAEAPC
FHC70935FMedicaidCA

Other names 1

  • Ravenswood Family Health Network Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20030919000000 CA Part A Provider - Federally Qualified Health Center (FQHC) 3577474634 Practice locations: East Palo Alto, CA
O20050720000602 CA Part B Supplier - Clinic/Group Practice 3577474634 Receives reassigned benefits from 12 practitioners
Practice locations: East Palo Alto, CA; Menlo Park, CA

Federally qualified health center certification: CCN 551946

Legal name
SOUTH COUNTY COMMUNITY HEALTH CENTER INC
Doing business as
RAVENSWOOD FAMILY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 18, 2003
Last certification
Dec 18, 2003
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 15, 2000 in CA
Enrollment address
1885 Bay Rd
East Palo Alto, CA 94303-1312

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory

Locations

100 Terminal Ave
Menlo Park, CA 94025
Phone (650) 321-0980

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
Julio Garcia Individual Corporate DirectorBoard Member Oct 24, 2003
Gralyn a Jacques Individual Corporate DirectorCfo Jul 1, 2019
W-2 Managing EmployeeCfo Jul 1, 2019
Operational/Managerial ControlCfo Jul 1, 2019
Esmeralda Garcia Individual Corporate DirectorBoard Member Mar 19, 2019
Luisa M Buada Individual Corporate DirectorCeo Nov 6, 2000
Fred Mondragon Individual Corporate DirectorBoard Member Dec 18, 2018
Marcelline Combs Individual Corporate DirectorBoard Member Oct 24, 2003
Manuel Arteaga Individual Corporate DirectorBoard Member Oct 24, 2003
Sherri Sager Individual Corporate Director Apr 1, 2004
Siteri Maravou Individual Corporate DirectorBoard Member Jun 21, 2011
Vyjeyanthi S Periyakoil Individual Corporate DirectorBoard Member Jan 15, 2019
Melieni Talakai Individual Corporate DirectorBoard Member Oct 24, 2003
Senseria Conley Individual Corporate DirectorBoard Member Oct 24, 2003
Genesis Cerna Individual Corporate DirectorBoard Member Nov 20, 2018

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 3

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

FacilityTypeRoleSince
Mayview Community Health Center Palo Alto, a Member of Ravenswood FamiPalo Alto, CA, CCN 551050 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2020
Apr 1, 2020
Mayview Community Health Center Mountain View a Member of RaMountain View, CA, CCN 551084 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Apr 1, 2020
Apr 1, 2020
Mayview Community Health Center Sunnyvale, a Member of Ravenswood FamiSunnyvale, CA, CCN 551085 Federally qualified health center 5% Or Greater Direct Ownership Interest
Operational/Managerial Control (100%)		 Apr 1, 2020
Apr 1, 2020

Owned or controlled facilities with NPI records 3

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

Practitioners & affiliated clinicians

Practitioners 28

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

View all 28

NPI Registry JSON

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

{
    "created_epoch": "1161216000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643673600000",
    "number": "1821170044",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1885 BAY ROAD",
            "city": "EAST PALO ALTO",
            "state": "CA",
            "postal_code": "943031611",
            "telephone_number": "650-330-7400",
            "fax_number": "650-321-1560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1885 BAY ROAD",
            "city": "EAST PALO ALTO",
            "state": "CA",
            "postal_code": "943031611",
            "telephone_number": "650-330-7400",
            "fax_number": "650-321-1560"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH COUNTY COMMUNITY HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-19",
        "last_updated": "2022-02-01",
        "certification_date": "2022-02-01",
        "status": "A",
        "authorized_official_last_name": "JACQUES",
        "authorized_official_first_name": "GRALYN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "650-330-7400",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "CA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CANCER DETECTION PROGRAM",
            "identifier": "BCP70935F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FAMILY PACT",
            "identifier": "HAP70935F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EAPC",
            "identifier": "EAP70935F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70935F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ravenswood Family Health Network",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in East Palo Alto, CA

Sources for this page

Verify at the official NPI Registry.