NPIMap

Organization Active NPI

The Los Angeles Free Clinic

  • Federally Qualified Health Center (FQHC)
  • Los Angeles, CA
National Provider Identifier
1932755907
Registry record updated Jun 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
THE LOS ANGELES FREE CLINIC
Practice address
6636 Selma Ave
Los Angeles, CA 90028-7115
Phone
(323) 653-1990
NPI assigned
Aug 14, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2021

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

Authorized official

Name
Ms. Muriel Nouwezem
Title
Chief Executive Officer
Phone
(323) 337-1707

Specialties & licenses 1

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

Addresses

Primary practice location

6636 Selma Ave
Los Angeles, CA 90028-7115

Mailing address

8405 Beverly Blvd
Los Angeles, CA 90048-3401

Other names 1

  • Saban Community Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200901002180 CA Part A Provider - Federally Qualified Health Center (FQHC) 5395886311 Practice locations: Los Angeles, CA

Federally qualified health center certification: CCN 921931

Legal name
THE LOS ANGELES FREE CLINIC
Doing business as
SABAN COMMUNITY CLINIC THE CENTER AT BLESSED SACRAMENT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 24, 2020
Last certification
Aug 24, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 14, 1967 in CA
Enrollment address
6636 Selma Ave
Los Angeles, CA 90028-7115

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
Tax ID family
The Los Angeles Free Clinic - Mobile Clinic7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

Locations

6636 Selma Ave
Los Angeles, CA 90028
Phone (323) 460-6220

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Carol Bultrago Individual Corporate DirectorBoard Member Jan 15, 2019
Jackie M Provost Individual W-2 Managing EmployeeChief Operations Officer Jul 13, 2020
Richard K Rifenbark Individual Corporate DirectorBoard Member Jan 15, 2019
Peggy B Miles Individual Corporate DirectorBoard Member Jan 21, 2020
Eric Jung Individual Corporate DirectorBoard Member Jan 16, 2018
Karen a Sanchez Individual Corporate DirectorBoard Member Jan 15, 2019
Michael L Ziering Individual Corporate DirectorBoard Member Jan 21, 2020
Russell a Orozco Individual Corporate DirectorBoard Member Jan 21, 2020
Jesse L Bronner Individual Corporate DirectorBoard Member Jan 15, 2019
The Los Angeles Free Clinic Organization, Los Angeles, CA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 28, 2020 100%
Ingrid Palmer Individual Corporate DirectorBoard Member Jan 15, 2019
Celia Brugman Individual Corporate DirectorBoard Member Jan 15, 2019
Samuel J Zinberg Individual Corporate DirectorBoard Member Jan 15, 2019
Angela L Jones Individual Corporate DirectorBoard Member Jan 21, 2020
Luis Pardo Individual Corporate DirectorBoard Member Jan 15, 2019
Mitchell R Pindus Individual Corporate DirectorBoard Member Jan 21, 2020
Joanne Dietch Individual Corporate OfficerSecretary Jan 21, 2020
Corporate DirectorBoard Secretary Jan 21, 2020
Muriel Nouwezem Individual Corporate OfficerCeo and Cfo Jun 1, 2018

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Saban Community ClinicLos Angeles, CA, CCN 551181 Federally qualified health center Other (100%) Dec 14, 1967
Saban Community Clinic - the VirgilLos Angeles, CA, CCN 921932 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Apr 13, 2020

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

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

{
    "created_epoch": "1565740800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623196800000",
    "number": "1932755907",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8405 BEVERLY BLVD",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900483401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6636 SELMA AVE",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900287115",
            "telephone_number": "323-653-1990"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE LOS ANGELES FREE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-14",
        "last_updated": "2021-06-09",
        "certification_date": "2021-06-09",
        "status": "A",
        "authorized_official_last_name": "NOUWEZEM",
        "authorized_official_first_name": "MURIEL",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "323-337-1707",
        "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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Saban Community Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Saban Community Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Los Angeles, CA

Sources for this page

Verify at the official NPI Registry.