NPIMap

Organization Active NPI

Celebrating Life Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Costa Mesa, CA
National Provider Identifier
1841913951
Registry record updated Sep 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CELEBRATING LIFE COMMUNITY HEALTH CENTER
Practice address
700 W 19TH St Ste a&B
Costa Mesa, CA 92627-3517
Phone
(949) 866-3600
NPI assigned
Sep 22, 2022
Last updated
Sep 22, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 22, 2022

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

Authorized official

Name
Mr. Sergey P Sergeyev
Title
Ceo
Phone
(949) 866-3600

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

700 W 19TH St Ste a&B
Costa Mesa, CA 92627-3517

Mailing address

27800 Medical Center Rd Ste 110
Mission Viejo, CA 92691-6407
Phone (949) 433-6686

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230404002279 CA Part A Provider - Federally Qualified Health Center (FQHC) 4789015140 Practice locations: Costa Mesa, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1841913951. Details of each certification follow.

Federally qualified health center certification: CCN 051967

Legal name
CELEBRATING LIFE COMMUNITY HEALTH CENTER
Doing business as
CLCHC - SANO COSTA MESA
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 31, 2023
Last certification
Mar 31, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 25, 2019 in CA
Enrollment address
700 W 19TH St
Ste a&B
Costa Mesa, CA 92627-3517

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
Celebrating Life Community Health Center9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

700 W 19th St
Ste Ab
Costa Mesa, CA 92627
Phone (949) 433-6686

27800 Medical Center Rd
Ste 110
Mission Viejo, CA 92691
Phone (949) 364-9255

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
John N Le Individual Corporate OfficerChief Medical Officer Jul 1, 2019
W-2 Managing EmployeeChief Medical Officer Jul 1, 2019
Randolph Phillip Velasco Individual Corporate Director Dec 26, 2018
Valentina Artemova Individual Corporate Director Dec 26, 2018
Sergey Sergeyev Individual Corporate OfficerChief Executive Officer Sep 20, 2018
Sylvia Caliendo Individual Corporate Director Dec 26, 2018

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1663804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663804800000",
    "number": "1841913951",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "27800 MEDICAL CENTER RD STE 110",
            "city": "MISSION VIEJO",
            "state": "CA",
            "postal_code": "926916407",
            "telephone_number": "949-433-6686"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 W 19TH ST STE A&B",
            "city": "COSTA MESA",
            "state": "CA",
            "postal_code": "926273517",
            "telephone_number": "949-866-3600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CELEBRATING LIFE COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-22",
        "last_updated": "2022-09-22",
        "certification_date": "2022-09-22",
        "status": "A",
        "authorized_official_last_name": "SERGEYEV",
        "authorized_official_first_name": "SERGEY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "949-866-3600",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Costa Mesa, CA

Sources for this page

Verify at the official NPI Registry.