Healthcare Provider Details

I. General information

NPI: 1164606414
Provider Name (Legal Business Name): NORTHEAST COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 N FIGUEROA ST
LOS ANGELES CA
90042
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 323-256-3884
  • Fax: 323-258-6307
Mailing address:
  • Phone: 626-457-6900
  • Fax: 626-457-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberHAP11584G
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberHAP11584G
License Number StateCA

VIII. Authorized Official

Name: DR. CHRISTOPHER LAU
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 626-457-6900