Dos Palos Apex Health Center Inc
Organization Active NPI Rural Health Clinic/Center · Dos Palos, CA
NPI 1831623453 · NPPES record last updated Apr 20, 2017
Key facts
- NPI
- 1831623453
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 3992639 (CA)
- Legal business name
- DOS PALOS APEX HEALTH CENTER INC
- Practice address
- 1549 Golden Gate St.
Dos Palos, CA 93620-2329 - Phone
- (209) 392-0022
- NPI assigned
- Apr 20, 2017
- Organization subpart
- No
Authorized official
- Name
- Karthikeya Devireddy
- Title
- Medical Director
- Phone
- (209) 392-0022
Owners & managing parties with NPI records 1
Practitioners 13
-
Vijay Devireddy, M.D.
-
Daniel E Hardy, M.D.
-
Bipin Kandel, M.D.
-
Savuth Kem, PA C
-
Monif Moussa Matouk, DPM
-
Sarah Ann S Matouk, D.P.M.
-
Juliette E Tamagni, PA-C
-
Kheng Xiong, PA-C
-
Kuw Xiong, P.A.
-
Yee Xiong, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D2142598 | Dos Palos Apex Health Center Inc | Certificate of waiver | Jan 15, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
Rural health clinic certification: CCN 058999
- Legal name
- DOS PALOS APEX HEALTH CENTER INC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 5, 2019
- Last certification
- Apr 5, 2019
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- Mar 6, 2017 in CA
- Enrollment address
- 1549 Golden Gate Ave
Dos Palos, CA 93620-2329
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Karthikeya Devireddy |
5% Or Greater Direct Ownership Interest |
Mar 6, 2017 | 70% |
| Corporate Officer |
Mar 6, 2017 | 70% | |
| Deborah Perry |
5% Or Greater Direct Ownership Interest |
Mar 6, 2017 | 30% |
| W-2 Managing Employee |
Mar 6, 2017 | 30% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20170913000124 | CA | Part a Provider - Rural Health Clinic | 3173896172 | Practice locations: Dos Palos, CA |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 3992639 | CA | Yes |
Addresses
Primary practice location
1549 Golden Gate St.
Dos Palos, CA 93620-2329
Mailing address
1549 Golden Gate Ave
Dos Palos, CA 93620-2329
Phone (209) 392-0022
Other providers in Dos Palos, CA
- George Randall Barsamian
- Robert Allen Bertelli
- Lety Elizabeth Costa
- Dos Palos Memorial Hospital, Inc
- Dos Palos-Oro Loma Jusd
- Chester Flakes Jr.
- Elizabeth Fonseca
- Alice Ruth Foster-Smith
All providers in Dos Palos, CA · Rural Health 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 Apr 20, 2017. 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.