Healthcare Provider Details

I. General information

NPI: 1891028171
Provider Name (Legal Business Name): NORTHEAST COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2009
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 300
HAWTHORNE CA
90250-2240
US

IV. Provider business mailing address

2550 W MAIN ST SUITE 301
ALHAMBRA CA
91801-1694
US

V. Phone/Fax

Practice location:
  • Phone: 310-645-0444
  • Fax: 310-978-0599
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: DR. CHRISTOPHER TAK LAU
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 626-457-6900