Provider Demographics
NPI:1164606414
Name:NORTHEAST COMMUNITY CLINIC
Entity Type:Organization
Organization Name:NORTHEAST COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-457-6900
Mailing Address - Street 1:2550 W MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1694
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:626-457-1233
Practice Address - Street 1:5420 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042
Practice Address - Country:US
Practice Address - Phone:323-256-3884
Practice Address - Fax:323-258-6307
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-21
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP11584G207R00000X, 207V00000X, 363A00000X, 363L00000X, 207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP11584GMedicaid