Provider Demographics
NPI:1568607539
Name:NORTHEAST COMMUNITY CLINIC
Entity Type:Organization
Organization Name:NORTHEAST COMMUNITY CLINIC
Other - Org Name:NORTHEAST COMMUNITY CLINIC MOBILE MEDICAL VAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
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
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:626-457-5022
Practice Address - Street 1:5820 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4228
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:2008-12-04
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM71120FMedicaid
CA551032Medicare Oscar/Certification