Healthcare Provider Details

I. General information

NPI: 1336790914
Provider Name (Legal Business Name): NORTHEAST COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 W 117TH ST STE 502
HAWTHORNE CA
90250-2261
US

IV. Provider business mailing address

2550 W MAIN ST STE 301
ALHAMBRA CA
91801-7003
US

V. Phone/Fax

Practice location:
  • Phone: 424-236-4800
  • Fax: 424-236-4801
Mailing address:
  • Phone: 626-457-6900
  • Fax: 626-457-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER TAK LAU
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 626-457-6900