NPIMap

Organization Active NPI

Harbor Community Clinic Inc

  • Pediatrics Physician
  • San Pedro, CA
National Provider Identifier
1831739614
Registry record updated Jan 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
HARBOR COMMUNITY CLINIC INC
Practice address
425 S Pacific Ave
San Pedro, CA 90731-2625
Phone
(310) 547-0202
Fax
(310) 547-0202
NPI assigned
Jan 9, 2020
Last updated
Jan 9, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 9, 2020

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

Authorized official

Name
Tamra King
Title
Chief Executive Officer
Phone
(310) 547-8241

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

425 S Pacific Ave
San Pedro, CA 90731-2625

Mailing address

593 W 6TH St
San Pedro, CA 90731-2521
Phone (310) 547-0202

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090505000470 CA Part B Supplier - Clinic/Group Practice 8022166826 Receives reassigned benefits from 22 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: San Pedro, CA
O20230505000998 CA Part A Provider - Federally Qualified Health Center (FQHC) 8022166826 Practice locations: San Pedro, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1831739614. Details of each certification follow.

Federally qualified health center certification: CCN A01171

Legal name
HARBOR COMMUNITY CLINIC INC
Doing business as
HARBOR COMMUNITY HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 8, 2023
Last certification
May 8, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 9, 2006 in CA
Enrollment address
425 S Pacific Ave
San Pedro, CA 90731-2625

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Harbor Community Clinic Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Locations

593 W 6th St
San Pedro, CA 90731
Phone (310) 547-0202

731 S Beacon St
San Pedro, CA 90731
Phone (310) 547-0202

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Tamra King Individual Corporate OfficerCeo Mar 1, 2020
W-2 Managing EmployeeCeo Mar 1, 2020
Dahina Hernandez Individual W-2 Managing EmployeeDirector of Administration Mar 1, 2020
Margie Lunt Individual Corporate DirectorBoard Member Aug 24, 2022
Yessenia E Henriquez Individual Corporate OfficerCfo Mar 1, 2020
W-2 Managing EmployeeCfo Mar 1, 2020
Jane Castillo Individual Corporate DirectorBoard Member Aug 24, 2022
Alan D Weinfeld Individual Corporate DirectorBoard Member Aug 24, 2022
Ida Taylor Individual Corporate DirectorBoard Member Aug 24, 2022
Deborah Olson Individual Corporate DirectorBoard Member Aug 24, 2022
Christopher Walter Individual Corporate OfficerCoo Aug 24, 2022
W-2 Managing EmployeeCoo Aug 24, 2022
Michael Lansing Individual Corporate DirectorBoard Member Aug 24, 2022
Bianca Banks Individual Corporate DirectorBoard Member Aug 24, 2022
Chad S Sparks Individual Corporate DirectorBoard Member Aug 24, 2022

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 24

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 24

NPI Registry JSON

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

{
    "created_epoch": "1578528000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1578528000000",
    "number": "1831739614",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "593 W 6TH ST",
            "city": "SAN PEDRO",
            "state": "CA",
            "postal_code": "907312521",
            "telephone_number": "310-547-0202",
            "fax_number": "310-547-5096"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 S PACIFIC AVE",
            "city": "SAN PEDRO",
            "state": "CA",
            "postal_code": "907312625",
            "telephone_number": "310-547-0202",
            "fax_number": "310-547-0202"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HARBOR COMMUNITY CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-09",
        "last_updated": "2020-01-09",
        "certification_date": "2020-01-09",
        "status": "A",
        "authorized_official_last_name": "KING",
        "authorized_official_first_name": "TAMRA",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "310-547-8241"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in San Pedro, CA

Sources for this page

Verify at the official NPI Registry.