Provider Demographics
NPI:1558068098
Name:CELEBRATING LIFE COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:CELEBRATING LIFE COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SERGEYEV
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:949-433-6686
Mailing Address - Street 1:27800 MEDICAL CENTER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6407
Mailing Address - Country:US
Mailing Address - Phone:949-433-6686
Mailing Address - Fax:
Practice Address - Street 1:15785 LAGUNA CANYON RD STE 250
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3179
Practice Address - Country:US
Practice Address - Phone:949-866-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386273100Medicaid