NPIMap

Organization Active NPI

Southern California Medical Center, Inc.

  • Community Health Clinic/Center
  • Pomona, CA
National Provider Identifier
1821625872
Registry record updated Jun 13, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
SOUTHERN CALIFORNIA MEDICAL CENTER, INC.
Practice address
502 W Holt Ave
Pomona, CA 91768-3604
Phone
(909) 620-8500
Fax
(909) 620-5799
NPI assigned
Mar 26, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2023

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

Authorized official

Name
Ellie Zare
Title
Sr. Program Manager
Phone
(818) 650-6700

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X
Clinic/Center 261Q00000X
Community Health Clinic/Center 261QC1500X Primary
Dental Clinic/Center 261QD0000X
Non-Surgical Family Planning Clinic/Center 261QF0050X
Federally Qualified Health Center (FQHC) 261QF0400X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Mammography Clinic/Center 261QR0206X

Addresses

Primary practice location

502 W Holt Ave
Pomona, CA 91768-3604

Mailing address

PO Box 436
Van Nuys, CA 91408-0436
Phone (818) 421-0809

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200414000620 CA Part A Provider - Federally Qualified Health Center (FQHC) 2769666817 Practice locations: Pomona, CA

Federally qualified health center certification: CCN 921873

Legal name
SOUTHERN CALIFORNIA MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 10, 2020
Last certification
Apr 10, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 14, 2008 in CA
Enrollment address
502 W Holt Ave
Pomona, CA 91768-3604

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Southern California Medical4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

502 W Holt Ave
Pomona, CA 91768
Phone (909) 620-5699

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Lourdes Martinez Vargas Individual Corporate OfficerBoard Member Sep 1, 2011
Southern California Medical Center Inc Organization, Van Nuys, CA Created for acquisition, Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 22, 2020 100%
Sheila Busheri Individual Corporate OfficerCeo Sep 1, 2011
Maria Ahumada Individual Corporate OfficerBoard Member Sep 1, 2011
Rosa Estorga Individual Corporate OfficerBoard Member Sep 1, 2011
Naveed Torian Individual Corporate OfficerBoard Member Sep 1, 2011
Gabriela Cabrera Individual W-2 Managing EmployeeQuality Assurance and Improvmt MNGR May 28, 2019

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
Southern California Medical Center-Pico RiveraPico Rivera, CA, CCN 751049 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 5, 2008
Southern California Medical CenterEl Monte, CA, CCN 751966 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 5, 2008
Southern California Medical Center IncVan Nuys, CA, CCN 751943 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2011
Southern California Medical CenterLong Beach, CA, CCN 921960 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 5, 2008
Southern California Medical Center IncWoodland Hills, CA, CCN A01885 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) May 5, 2008

Owned or controlled facilities with NPI records 5

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

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

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

{
    "created_epoch": "1585180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1686614400000",
    "number": "1821625872",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 436",
            "city": "VAN NUYS",
            "state": "CA",
            "postal_code": "914080436",
            "telephone_number": "818-421-0809",
            "fax_number": "909-620-5799"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "502 W HOLT AVE",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917683604",
            "telephone_number": "909-620-8500",
            "fax_number": "909-620-5799"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN CALIFORNIA MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-26",
        "last_updated": "2023-06-13",
        "certification_date": "2023-06-13",
        "status": "A",
        "authorized_official_last_name": "ZARE",
        "authorized_official_first_name": "ELLIE",
        "authorized_official_title_or_position": "SR. PROGRAM MANAGER",
        "authorized_official_telephone_number": "818-650-6700"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0050X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Family Planning, Non-Surgical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0206X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology, Mammography",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pomona, CA

Sources for this page

Verify at the official NPI Registry.