MEDICARE: NORTHEAST COMMUNITY CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1881987576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST COMMUNITY CLINIC

Provider Business Mailing Address
First Line	:	2550 W MAIN ST STE 301
Second Line	:
City	:	ALHAMBRA
State	:	CA
Zip	:	91801-7003
Country	:	US
Telephone Number	:	626-457-6900
Fax Number	:	626-457-1233

Provider Business Practice Location Address
First Line	:	2822 E FLORENCE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-5749
Country	:	US
Telephone Number	:	323-923-1900
Fax Number	:	323-923-1905

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. CHRISTOPHER LAU
Credential	:
Telephone Number	:	626-457-6900

Provider Enumeration Date	:	05/27/2011
Last Update Date	:	10/15/2021

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