NPIMap

Organization Active NPI

Northeast Community Clinic

  • Federally Qualified Health Center (FQHC)
  • Hawthorne, CA
National Provider Identifier
1891028171
Registry record updated Oct 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST COMMUNITY CLINIC
Practice address
4455 W 117TH St Ste 300
Hawthorne, CA 90250-2240
Phone
(310) 645-0444
Fax
(310) 978-0599
NPI assigned
Sep 17, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 15, 2021

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

Authorized official

Name
Dr. Christopher Tak Lau, MDNPI 1548365968
Title
Executive Director
Phone
(626) 457-6900

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

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

Addresses

Primary practice location

4455 W 117TH St Ste 300
Hawthorne, CA 90250-2240

Mailing address

2550 W Main St
Suite 301
Alhambra, CA 91801-1694
Phone (626) 457-6900

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040417000619 CA Part B Supplier - Clinic/Group Practice 5193710275 Receives reassigned benefits from 65 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bell, CA; Harbor City, CA; Hawthorne, CA; Huntington Park, CA; Los Angeles, CA; Wilmington, CA
O20111117000738 CA Part A Provider - Federally Qualified Health Center (FQHC) 5193710275 Practice locations: Hawthorne, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1891028171. Details of each certification follow.

Federally qualified health center certification: CCN 551122

Legal name
NORTHEAST COMMUNITY CLINIC
Doing business as
NORTHEAST COMMUNITY CLINIC-HAWTHORNE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 17, 2011
Last certification
Nov 17, 2011
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 27, 1971 in CA
Enrollment address
4455 W 117TH St
Ste 300
Hawthorne, CA 90250-2240

Other NPIs with the same Medicare PAC ID 13

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

View all 13

Other NPIs on the same Medicare enrollment 11

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Melissa M Aguilar Individual Corporate DirectorBoard Member Mar 2, 2006
Octavio Fierros Individual Corporate DirectorBoard of Director Mar 10, 2021
Fumio Robert Nakahiro Individual Corporate DirectorBoard Member May 19, 1999
Irene Huerta Individual Corporate DirectorBoard of Director Mar 21, 2018
Ali Mohammad Tweini Individual Corporate DirectorBoard of Director Aug 11, 2021
Valery Marquez Perez Individual Corporate DirectorBoard of Director Aug 11, 2021
Christopher T Lau Individual Corporate DirectorExecutive Director Aug 1, 2011
W-2 Managing EmployeeExecutive Director Aug 7, 1997
Ruby Y Medrano Individual Corporate DirectorBoard Member Jan 12, 2006
Mark Gonzalez Individual Corporate DirectorBoard Member Mar 11, 2010
Dalia M Jaramillo Individual Corporate DirectorBorad Member Jul 6, 2006
Monica Guardian Individual Corporate DirectorBoard Member Jun 1, 2016
Katrina Manning Individual Corporate DirectorBoard of Director Mar 9, 2017
Patricia Sanders Individual Corporate DirectorBorad Member Jun 1, 2016

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 8

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": "1253145600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634256000000",
    "number": "1891028171",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2550 W MAIN ST",
            "address_2": "SUITE 301",
            "city": "ALHAMBRA",
            "state": "CA",
            "postal_code": "918011694",
            "telephone_number": "626-457-6900",
            "fax_number": "626-457-5022"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4455 W 117TH ST STE 300",
            "city": "HAWTHORNE",
            "state": "CA",
            "postal_code": "902502240",
            "telephone_number": "310-645-0444",
            "fax_number": "310-978-0599"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST COMMUNITY CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-09-17",
        "last_updated": "2021-10-15",
        "certification_date": "2021-10-15",
        "status": "A",
        "authorized_official_last_name": "LAU",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "TAK",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "626-457-6900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "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 Hawthorne, CA

Sources for this page

Verify at the official NPI Registry.