NPIMap

Organization Active NPI

Northeast Community Clinic

  • Federally Qualified Health Center (FQHC)
  • Hawthorne, CA
National Provider Identifier
1962050120
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 200
Hawthorne, CA 90250-2240
Phone
(310) 219-2000
Fax
(310) 219-2001
NPI assigned
Aug 30, 2019
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
Christopher Tak Lau, MD
Title
Executive Director
Phone
(626) 457-6900

Specialties & licenses 1

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

Addresses

Primary practice location

4455 W 117TH St Ste 200
Hawthorne, CA 90250-2240

Mailing address

2550 W Main St Ste 301
Alhambra, CA 91801-7003
Phone (626) 457-6900

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200123001599 CA Part A Provider - Federally Qualified Health Center (FQHC) 5193710275 Practice locations: Hawthorne, CA

Federally qualified health center certification: CCN 921829

Legal name
NORTHEAST COMMUNITY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 7, 2020
Last certification
Jan 7, 2020
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
May 27, 1971 in CA
Enrollment address
4455 W 117TH St
Ste 200
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

National Provider Directory

National Provider Directory
Tax ID family
Northeast Community Clinic9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Octavio Fierros Individual Corporate Director Mar 10, 2021
Fumio Robert Nakahiro Individual Corporate DirectorBoard of Director May 16, 1999
Irene Huerta Individual Corporate DirectorBoard of Director Mar 21, 2018
Ali Mohammad Tweini Individual Corporate Director Aug 11, 2021
Christopher T Lau Individual Corporate DirectorExecutive Director Aug 4, 1997
W-2 Managing EmployeeExecutive Director Aug 4, 1997
Ruby Y Medrano Individual Corporate DirectorBoard of Director Jan 12, 2006
Dalia M Jaramillo Individual Corporate DirectorBoard of Director Jul 6, 2006
Monica Guardian Individual Corporate DirectorBoard of Director Jan 1, 2015
Renia Carrillo Individual Corporate Director Nov 8, 2023
Carlos Soto Individual Corporate Director Mar 13, 2024

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1567123200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634256000000",
    "number": "1962050120",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2550 W MAIN ST STE 301",
            "city": "ALHAMBRA",
            "state": "CA",
            "postal_code": "918017003",
            "telephone_number": "626-457-6900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4455 W 117TH ST STE 200",
            "city": "HAWTHORNE",
            "state": "CA",
            "postal_code": "902502240",
            "telephone_number": "310-219-2000",
            "fax_number": "310-219-2001"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST COMMUNITY CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-30",
        "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_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.