NPIMap

Organization Active NPI

Mendocino Community Health Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Willits, CA
National Provider Identifier
1922020585
Registry record updated May 3, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Practice address
45 Hazel St
Willits, CA 95490
Phone
(707) 456-9600
NPI assigned
Jul 24, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 3, 2019

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

Authorized official

Name
Mr. Tim Dolan
Title
Cfo
Phone
(707) 467-2260

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 110000500 CA
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

45 Hazel St
Willits, CA 95490

Mailing address

333 Laws Ave
Ukiah, CA 95482-6540
Phone (707) 468-1010

Other identifiers 2

IdentifierTypeStateIssuer
HAP70968FOtherCAFAMILYPACT
FHC70968FMedicaidCA

Other names 1

  • Little Lake Health Center Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030331000024 CA Part A Provider - Federally Qualified Health Center (FQHC) 6305755455 Practice locations: Willits, CA

Federally qualified health center certification: CCN 551926

Legal name
MENDOCINO COMMUNITY HEALTH CLINIC INC
Doing business as
LITTLE LAKE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 3, 2003
Last certification
Jun 3, 2003
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 2, 1991 in CA
Enrollment address
45 Hazel St
Willits, CA 95490-4222

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory

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
Ben Anderson Individual Corporate OfficerCeo Mar 16, 2026
Victoria Kelly Individual Corporate Director Dec 1, 2021
Gary Wakeman Individual Corporate Director Mar 1, 2024
Carlos Frausto Individual Corporate Officer Dec 1, 2000
Martha Barra Individual Corporate Director Mar 1, 2024
Daniel McIntire Individual Corporate Director Mar 1, 2024
Carre Brown Individual Corporate Director Mar 1, 2021
Jackeline Gonzalez de Orozco Individual Corporate Director Jan 1, 2021
Stephen Miller Individual Corporate Director Sep 1, 2023
Kelly E Sanford Individual Corporate Officer Feb 2, 2026
W-2 Managing EmployeeAd; Feb 2, 2026
Pam Carr Individual W-2 Managing EmployeeBilling Manager Jun 19, 2000
John Pavoni Individual Corporate Director Jan 1, 2010

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 57

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 57

NPI Registry JSON

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

{
    "created_epoch": "1153699200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556841600000",
    "number": "1922020585",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "333 LAWS AVE",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954826540",
            "telephone_number": "707-468-1010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "45 HAZEL ST",
            "city": "WILLITS",
            "state": "CA",
            "postal_code": "95490",
            "telephone_number": "707-456-9600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDOCINO COMMUNITY HEALTH CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-24",
        "last_updated": "2019-05-03",
        "status": "A",
        "authorized_official_last_name": "DOLAN",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "707-467-2260",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "CA",
            "license": "110000500",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FAMILYPACT",
            "identifier": "HAP70968F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70968F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Little Lake Health Center",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Little Lake Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Willits, CA

Sources for this page

Verify at the official NPI Registry.