Provider Demographics
NPI:1013057371
Name:ST. JOHNS COMMUNITY HEALTH
Entity Type:Organization
Organization Name:ST. JOHNS COMMUNITY HEALTH
Other - Org Name:ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANGIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-541-1660
Mailing Address - Street 1:808 W 58TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3632
Mailing Address - Country:US
Mailing Address - Phone:323-541-1660
Mailing Address - Fax:323-541-1661
Practice Address - Street 1:5701 S HOOVER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-4045
Practice Address - Country:US
Practice Address - Phone:323-541-1400
Practice Address - Fax:323-541-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171W00000X, 251B00000X, 251X00000X, 261QF0400X
CA550000088261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251X00000XAgenciesSupports Brokerage
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC 71106FMedicaid
CA1013057371Medicaid
CAW16114BMedicare PIN
CA551069Medicare Oscar/Certification
CAW16114BMedicare PIN
CA1841331667OtherNOMSA KHALFANI
CAW16114BMedicare PIN
CA1043387368OtherJAMES GRAY
CAHAP71106FMedicaid
CA551069Medicare PIN