NPIMap

Organization Active NPI

Livingstone Community Development Corporation

Doing business as Livingstone Community Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Stanton, CA
National Provider Identifier
1952662686
Registry record updated Jun 20, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LIVINGSTONE COMMUNITY DEVELOPMENT CORPORATION
Doing business as
Livingstone Community Health Clinic
Practice address
12362 Beach Blvd Ste 10
Stanton, CA 90680-3944
Phone
(714) 248-9500
Fax
(714) 622-4943
NPI assigned
May 29, 2012
Last updated
Jun 20, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 20, 2020

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

Authorized official

Name
Dr. Kyung I. Park, MDNPI 1942210570
Title
Ceo
Phone
(714) 248-9500

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

12362 Beach Blvd Ste 10
Stanton, CA 90680-3944

Mailing address

12362 Beach Blvd Ste 10
Stanton, CA 90680-3944
Phone (714) 248-9500

Other names 1

  • Livingstone Community Health Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20140724002386 CA Part B Supplier - Clinic/Group Practice 9931323706 Receives reassigned benefits from 12 practitioners
1 other NPI on this enrollment
Practice locations: Fullerton, CA; Stanton, CA
O20171130003292 CA Part A Provider - Federally Qualified Health Center (FQHC) 9931323706 Practice locations: Stanton, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1952662686. Details of each certification follow.

Federally qualified health center certification: CCN 921029

Legal name
LIVINGSTONE COMMUNITY DEVELOPMENT CORPORATION
Doing business as
LIVINGSTONE COMMUNITY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 21, 2017
Last certification
Nov 21, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 2009 in CA
Enrollment address
12362 Beach Blvd
Ste 10
Stanton, CA 90680-3944

Other NPIs on the same Medicare enrollment 1

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D2052364Livingstone Community Health Clinic12362 Beach Blvd., Suite 10, Stanton, CA 90680Certificate of waiverJan 8, 2027

National Provider Directory

National Provider Directory
Tax ID family
Livingstone Community Development Corporation3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Jeannie Joung Individual Corporate DirectorBoard Chairperson Feb 24, 2020 5%
Nicholas S C Lee Individual Corporate DirectorBoard Member Feb 24, 2020 5%
Yong Hwan Lee Individual Corporate DirectorBoard Member Sep 1, 2017 5%
Kyung I Park Individual Corporate OfficerCeo, Cmo Sep 1, 2017 35%
W-2 Managing EmployeeCeo, Cmo Sep 1, 2017 35%
Operational/Managerial ControlCeo, Cmo Sep 1, 2017 35%
Brandy Taylor Individual Corporate DirectorBoard Member Aug 10, 2020 5%
Junghwa Lim Individual Corporate DirectorBoard Member Sep 1, 2017 5%
Hyun Joo Kim Individual Corporate OfficerCoo Sep 1, 2017 5%
W-2 Managing EmployeeCoo Sep 1, 2017 5%
Livingstone Community Development Corporation Organization, Stanton, CA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2017 100%

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 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1338249600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1592611200000",
    "number": "1952662686",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12362 BEACH BLVD STE 10",
            "city": "STANTON",
            "state": "CA",
            "postal_code": "906803944",
            "telephone_number": "714-248-9500",
            "fax_number": "714-622-4943"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12362 BEACH BLVD STE 10",
            "city": "STANTON",
            "state": "CA",
            "postal_code": "906803944",
            "telephone_number": "714-248-9500",
            "fax_number": "714-622-4943"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIVINGSTONE COMMUNITY DEVELOPMENT CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-29",
        "last_updated": "2020-06-20",
        "certification_date": "2020-06-20",
        "status": "A",
        "authorized_official_last_name": "PARK",
        "authorized_official_first_name": "KYUNG",
        "authorized_official_middle_name": "I.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "714-248-9500",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Livingstone Community Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Livingstone Community Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Stanton, CA

Sources for this page

Verify at the official NPI Registry.