Provider Demographics
NPI:1275226334
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:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:TAK
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 STE 301
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7003
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:626-457-5022
Practice Address - Street 1:4455 W. 117TH ST SUITE 105
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2241
Practice Address - Country:US
Practice Address - Phone:424-456-6200
Practice Address - Fax:424-456-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)