Shafter Pediatrics – Clinic/Center in Shafter, CA

Key facts

NPI: 1821763590
Entity type: Organization (NPI type 2)
Primary specialty: Clinic/Center 261Q00000X
Legal business name: SHAFTER PEDIATRICS
Practice address: 501 Munzer St
Suite C
Shafter, CA 93263-2042
Phone: (661) 630-5274
Fax: (661) 630-5290
NPI assigned: Aug 13, 2021
Organization subpart: Yes
Parent organization (as reported): SHAFTER PEDIATRICS

Authorized official

Name: Dr. Ayodeji Adetayo Ayeni, M.D. NPI 1831194331
Title: Medical Director
Phone: (661) 364-5244

Authorized official NPPES reports the authorized official by name only; the link goes to the one practitioner connected to this organization with that name.

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Shafter Pediatrics Pediatrics Physician · Shafter, CA · NPI 1811362908

NPPES parent name

Owners & managing parties with NPI records 1

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

Ayodeji Adetayo Ayeni, M.D Pediatrics Physician · Shafter, CA · NPI 1831194331

CMS ownership 5% OR GREATER DIRECT OWNERSHIP INTEREST

Other NPIs on the same Medicare enrollment 1

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

Shafter Pediatrics Pediatrics Physician · Shafter, CA · NPI 1811362908

Same enrollment O20160708000587

Other NPIs with the same Medicare PAC ID 1

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

Shafter Pediatrics Pediatrics Physician · Shafter, CA · NPI 1811362908

Same PAC ID 8628377041

Corporate family (same tax ID) 1

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

Shafter Pediatrics Pediatrics Physician · Shafter, CA · NPI 1811362908

NPD tax ID

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Shafter Urgent Care Urgent Care Clinic/Center · Shafter, CA · NPI 1376994533

NPD member Member Of

Practitioners 1

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

Ayodeji Adetayo Ayeni, M.D Pediatrics Physician · Shafter, CA · NPI 1831194331

NPD Authorized official PEDIATRICS

Laboratory certificates & supplier records

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

CLIA laboratory certificates

CLIA number	Laboratory	Certificate	Expires
05D2289448	Elmo Pediatrics & Family Walk-in Clinic 221 Elmo Hwy, Suite 100, MC Farland, CA 93250	Certificate of waiver	Sep 10, 2027

Medicare participation

Medicare fee-for-service enrollment: Enrolled (2 enrollments) in CA

Rural health clinic certification: CCN 558916

Legal name: SHAFTER PEDIATRICS
Doing business as: ELMO PEDIATRICS & FAMILY WALK-IN CLINIC
Certification status: Active
Provider type (POS): Rural health clinic
Participating since: Dec 20, 2023
Last certification: Dec 20, 2023
Ownership / control type: 1B
Organization structure: Corporation · Proprietary
Incorporated: May 4, 2021 in CA
Enrollment address: 221 Elmo Hwy
Ste a
McFarland, CA 93250-0000

All disclosed owners & managing parties 2

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

Name	Role	Since	Share
Novira P Sunner Individual	Contracted Managing Employee Manager	Jun 30, 2022
Ayodeji Adetayo Ayeni Individual	5% Or Greater Direct Ownership Interest	May 4, 2015	100%

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20160708000587	CA	Part B Supplier - Clinic/Group Practice	8628377041	Receives reassigned benefits from 2 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Shafter, CA; MC Farland, CA
O20240625003761	CA	Part a Provider - Rural Health Clinic	8628377041	Practice locations: McFarland, CA

National Provider Directory

Tax ID family: Shafter Pediatrics (2 organizations share this tax ID)
Part of: Shafter Pediatrics

Locations

2615 Chester Ave
Los Angeles, CA 90084

221 Elmo Hwy
#100
Mc Farland, CA 93250
Phone (661) 720-1883

221 Elmo Hwy
Ste A
Mc Farland, CA 93250
Phone (661) 720-1883

501 Munzer St
Ste C
Shafter, CA 93263
Phone (661) 364-5244

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Pediatrics Physician Group: 193400000X SINGLE SPECIALTY GROUP	208000000X
Clinic/Center	261Q00000X			Yes

Addresses

Primary practice location

501 Munzer St
Suite C
Shafter, CA 93263-2042

Mailing address

P.O. Box 22694
Bakersfield, CA 93390-2694
Phone (661) 630-5274

Other practice location 1

221 Elmo Hwy
Suite 100
McFarland, CA 93250-9325
Phone (661) 720-1883

Other identifiers

Identifier	Type	State	Issuer
552863	Other	CA	MEDICAL BOARD OF CALIFORNIA

Other names

Elmo pediatrics & family walk-in clinic Doing business as

Other providers in Shafter, CA

All providers in Shafter, CA · Clinic/Center in California

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 29, 2023. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
Provider of Services files (CMS): certification status, beds and related CCNs.
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.