Provider Demographics
NPI:1386912202
Name:EAST VALLEY COMMUNITY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:EAST VALLEY COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-919-4333
Mailing Address - Street 1:420 S GLENDORA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3001
Mailing Address - Country:US
Mailing Address - Phone:626-919-4333
Mailing Address - Fax:626-919-2084
Practice Address - Street 1:17840 VILLA CORTA ST
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-5342
Practice Address - Country:US
Practice Address - Phone:626-919-4333
Practice Address - Fax:626-919-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA550002062261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550002062OtherCA DEPARTMENT OF PUBLIC HEALTH LICENSE
CAFHC12048FMedicaid