NPIMap

Organization Active NPI

Mendocino Coast Clinics, Inc.

  • Federally Qualified Health Center (FQHC)
  • Fort Bragg, CA
National Provider Identifier
1861670093
Registry record updated Jun 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MENDOCINO COAST CLINICS, INC.
Practice address
855 Sequoia Circle
Fort Bragg, CA 95437-5540
Phone
(707) 964-1251
Fax
(707) 961-2722
NPI assigned
Feb 11, 2008
Last updated
Jun 9, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2020

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

Authorized official

Name
Ms. Paula Cohen
Title
Executive Director
Phone
(707) 964-1251

Specialties & licenses 1

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

Addresses

Primary practice location

855 Sequoia Circle
Fort Bragg, CA 95437-5540

Mailing address

205 South St
Fort Bragg, CA 95437-5540
Phone (707) 964-1251

Other identifiers 1

IdentifierTypeStateIssuer
CMM71141FMedicaidCA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080520000671 CA Part A Provider - Federally Qualified Health Center (FQHC) 5991619157 Practice locations: Fort Bragg, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1861670093. Details of each certification follow.

Federally qualified health center certification: CCN 051145

Legal name
MENDOCINO COAST CLINICS, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 20, 2008
Last certification
Oct 20, 2008
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 27, 1992 in CA
Enrollment address
855 Sequoia Cir
Fort Bragg, CA 95437-5466

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
Mendocino Coast Clinics Inc6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Lucresha Renteria Individual Corporate OfficerExecutive Director Jan 1, 2017 100%
W-2 Managing EmployeeExecutive Director Jul 1, 1994 100%
Operational/Managerial ControlExecutive Director Jul 1, 1994 100%
Cindy Rusert Individual Corporate DirectorDirector Jan 5, 2026
Matt O'Halloran Individual Corporate DirectorDirector Jan 5, 2026
Trevor J. Orchard Individual Corporate DirectorDirector Jul 9, 2019
Kelly Grimes Individual Corporate Director Oct 26, 2016
James Katzel Individual Corporate DirectorVice Chair Jan 5, 2026
Daphne Haney Individual Corporate Officer Jun 9, 2015
Claire Amanno Individual Corporate DirectorDirector Jan 5, 2026
Rio Parfrey Individual Corporate DirectorDirector Mar 12, 2019
Araceli Rivas Individual Corporate DirectorDirector May 14, 2019
Yadira Sanchez Individual Corporate DirectorDirector Jul 11, 2019

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1202688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1591660800000",
    "number": "1861670093",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 SOUTH ST",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "954375540",
            "telephone_number": "707-964-1251",
            "fax_number": "707-961-2722"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "855 SEQUOIA CIRCLE",
            "city": "FORT BRAGG",
            "state": "CA",
            "postal_code": "954375540",
            "telephone_number": "707-964-1251",
            "fax_number": "707-961-2722"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COAST CLINICS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-11",
        "last_updated": "2020-06-09",
        "certification_date": "2020-06-09",
        "status": "A",
        "authorized_official_last_name": "COHEN",
        "authorized_official_first_name": "PAULA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "707-964-1251",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CMM71141F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Bragg, CA

Sources for this page

Verify at the official NPI Registry.