NPIMap

Organization Active NPI

Lake County Tribal Health Consortium Inc.

  • Federally Qualified Health Center (FQHC)
  • Lakeport, CA
National Provider Identifier
1881697381
Registry record updated Mar 3, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
110000289 Issued in CA
Legal business name
LAKE COUNTY TRIBAL HEALTH CONSORTIUM INC.
Practice address
925 Bevins CT
Lakeport, CA 95453-9754
Phone
(707) 263-8382
Fax
(707) 263-0329
NPI assigned
May 27, 2005
Last updated
Mar 3, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 3, 2026

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

Authorized official

Name
Mr. Ernesto Padilla Jr.
Title
Executive Director
Phone
(707) 263-8382

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 110000289 CA Primary

Addresses

Primary practice location

925 Bevins CT
Lakeport, CA 95453-9754

Mailing address

925 Bevins CT
Lakeport, CA 95453-9754
Phone (707) 263-8382

Other identifiers 1

IdentifierTypeStateIssuer
THP70611FMedicaidCA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040304000323 CA Part B Supplier - Clinic/Group Practice 8729975545 Receives reassigned benefits from 61 practitioners
1 other NPI on this enrollment
Practice locations: Clearlake, CA; Lakeport, CA
O20110412000085 CA Part A Provider - Federally Qualified Health Center (FQHC) 8729975545 Practice locations: Lakeport, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881697381. Details of each certification follow.

Federally qualified health center certification: CCN 051946

Legal name
LAKE COUNTY TRIBAL HEALTH CONSORTIUM INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 1, 1995
Last certification
Mar 1, 1995
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 27, 1987 in CA
Enrollment address
925 Bevins CT
Lakeport, CA 95453-9754

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

Locations

359 Lakeport Blvd
Lakeport, CA 95453
Phone (707) 533-2740

811 Bevins St
Lakeport, CA 95453

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Brian Carl John Individual Corporate Director Jan 1, 2017
Luya Kabuhayan Rivera Individual Corporate Director Jul 1, 2021
Mille Simon Individual Corporate Director Jan 1, 2017
Kathleen Dawn Treppa Individual Corporate Director Jul 1, 2021
Thomas Burnett Individual 5% Or Greater Direct Ownership Interest Jul 1, 2023
W-2 Managing Employee Jul 1, 2023
Leora Kabuhayan John Individual Corporate Director Jan 1, 2017
Crista Ray Individual Corporate Director Jan 1, 2017
Veronica Rael-Aparicio Individual Corporate Director Jan 1, 2017
Aaron Holstine Individual Corporate Director Jan 1, 2017
Jamie Miller Campanero Individual Corporate Director Jan 1, 2017
Jessica Gonzalez Individual Corporate Director Jan 1, 2017
Ernesto Padilla Individual Corporate Director Mar 29, 2011
Jesse Louise Gonzalez Individual Corporate Director Jan 1, 2017
Lanita Johnson Individual W-2 Managing EmployeeBilling Supervisor Oct 6, 2011

Practitioners & affiliated clinicians

Practitioners 71

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 71

NPI Registry JSON

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

{
    "created_epoch": "1117152000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1772496000000",
    "number": "1881697381",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "925 BEVINS CT",
            "city": "LAKEPORT",
            "state": "CA",
            "postal_code": "954539754",
            "telephone_number": "707-263-8382",
            "fax_number": "707-263-0329"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "925 BEVINS CT",
            "city": "LAKEPORT",
            "state": "CA",
            "postal_code": "954539754",
            "telephone_number": "707-263-8382",
            "fax_number": "707-263-0329"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE COUNTY TRIBAL HEALTH CONSORTIUM INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-05-27",
        "last_updated": "2026-03-03",
        "certification_date": "2026-03-03",
        "status": "A",
        "authorized_official_last_name": "PADILLA",
        "authorized_official_first_name": "ERNESTO",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "707-263-8382",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "110000289",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "THP70611F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lakeport, CA

Sources for this page

Verify at the official NPI Registry.