| Addresses | Billing Address | Insert | Recertification | | University Muslim Medical Association Inc
6814 Pacific Blvd.
Huntington Park, CA 90255 | 2/25/2025 6:53 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 1730421330 (CA) | | 2/25/2025 6:53 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1730421330 (CA) | | 2/25/2025 6:53 PM |
| Details | Last Recertification Date | Update | Recertification | 2/20/2024 1:48:49 PM | 2/25/2025 6:53:58 PM | 2/25/2025 6:53 PM |
| Contacts | Primary Contact | Update | Change Request | Barth-Rogers, Yohanna
Interim CMO
UMMA Community Clinic
3236867734 | Reynoso, Alfredo
Chief Operating Officer
University Muslim Medical Association Inc
3236471520 | 1/14/2025 2:01 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Syed, Adel
CEO
UMMA Community Clinic
3236867701 | Syed, Adel
CEO
UMMA Community Clinic
3232177298 | 10/14/2024 8:16 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2023 8:15:33 PM | 2/20/2024 1:48:49 PM | 2/20/2024 1:48 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2022 3:50:43 PM | 2/7/2023 8:15:33 PM | 2/7/2023 8:15 PM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2021 6:18:50 PM | 2/3/2022 3:50:43 PM | 2/3/2022 3:50 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 2/26/2021 4:54 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1730421330 | 2/26/2021 4:54 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | CA | 2/26/2021 4:54 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1730421330 | 2/26/2021 4:54 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | CA | 2/26/2021 4:54 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2020 12:11:43 AM | 2/4/2021 6:18:50 PM | 2/4/2021 6:18 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 12:53:50 PM | 1/31/2020 12:11:43 AM | 1/31/2020 12:11 AM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2018 2:06:17 PM | 1/29/2019 12:53:50 PM | 1/29/2019 12:53 PM |
| Contacts | Primary Contact | Update | Change Request | Barba, Cesar
Chief Medical Officer
UMMA Community Clinic
3236867765 | Barth-Rogers, Yohanna
Interim CMO
UMMA Community Clinic
3236867734 | 10/1/2018 2:44 PM |
| Details | Last Recertification Date | Update | Recertification | 1/27/2017 12:00:00 AM | 2/9/2018 2:06:17 PM | 2/9/2018 2:06 PM |
| Contacts | Authorizing Official | Update | Change Request | Vega, Miriam
CEO
3234065799 | Syed, Adel
CEO
UMMA Community Clinic
3236867701 | 2/2/2018 7:25 AM |
| Details | Is Authorizing Official EHB Data | Update | Change Request | False | | 2/2/2018 7:25 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Barba, Cesar
Chief Medical Information Officer
UMMA Community Clinic
3234049268 | Barba, Cesar
Chief Medical Officer
UMMA Community Clinic
3236867765 | 1/10/2018 6:59 PM |
| Contacts | Primary Contact | Update | | Barba, Cesar
Chief Medical Information Officer
3234049268 | Barba, Cesar
Chief Medical Information Officer
UMMA Community Clinic
3234049268 | 1/10/2018 6:47 PM |
| Addresses | Main Address | Insert | | |
7821 S. Avalon Blvd
Los Angeles, CA 90003-2348 | 1/27/2017 12:11 PM |
| Contacts | Authorizing Official | Update | | Provost, Jackie
COO
3234065784 | Vega, Miriam
CEO
3234065799 | 1/27/2017 12:11 PM |
| Contacts | Signed By | Insert | | | Johnson, Pat
VP of Operations
3234065790 | 1/27/2017 12:11 PM |
| Contacts | Primary Contact | Update | | Provost, Jackie
COO
3234065784 | Barba, Cesar
Chief Medical Information Officer
3234049268 | 1/27/2017 12:11 PM |
| Details | Last Recertification Date | Update | | 2/29/2016 12:00:00 AM | 1/27/2017 12:00:00 AM | 1/27/2017 12:10 PM |
| Contacts | Authorizing Official | Insert | | | Provost, Jackie
COO
3234065784 | 2/29/2016 1:58 PM |
| Contacts | Primary Contact | Insert | | | Provost, Jackie
COO
3234065784 | 2/29/2016 1:58 PM |
| Details | Last Recertification Date | Update | | | 2/29/2016 12:00:00 AM | 2/29/2016 1:58 PM |
| Dates | Participating Approval Date | Update | | | 1/22/2015 12:00:00 AM | 1/22/2015 4:58 PM |
| Details | State | Update | | Pending | Active | 1/22/2015 4:58 PM |
| Dates | Start Date | Update | | | 4/1/2015 12:00:00 AM | 1/22/2015 4:58 PM |
| Details | 340B ID | Update | | ONLINE_REG_48249 | CHC10609-01 | 1/6/2015 4:29 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_48249 | 1/6/2015 12:43 PM |
| Details | Last Recertification Date | Insert | | | | 1/6/2015 12:43 PM |
| Details | Grant Number | Insert | | | H80CS10609 | 1/6/2015 12:43 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/6/2015 12:43 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 1/6/2015 12:43 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/6/2015 12:43 PM |
| Details | Medicare Provider Number | Insert | | | | 1/6/2015 12:43 PM |
| Details | Entity Name | Insert | | | UNIVERSITY MUSLIM MEDICAL ASSOCIATION, INC. | 1/6/2015 12:43 PM |
| Details | Program Code | Insert | | | CH | 1/6/2015 12:43 PM |
| Details | Entity Subname | Insert | | | Fremont Wellness Center | 1/6/2015 12:43 PM |
| Dates | Participating Approval Date | Insert | | | | 1/6/2015 12:43 PM |
| Details | State | Insert | | | Pending | 1/6/2015 12:43 PM |
| Dates | Registration Date | Insert | | | 1/6/2015 12:00:00 AM | 1/6/2015 12:43 PM |
| Dates | Signed By Date | Insert | | | 1/6/2015 12:00:00 AM | 1/6/2015 12:43 PM |
| Dates | Start Date | Insert | | | | 1/6/2015 12:43 PM |
| Terminations | Termination Comments | Insert | | | | 1/6/2015 12:43 PM |
| Terminations | Termination Date | Insert | | | | 1/6/2015 12:43 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/6/2015 12:43 PM |
| Terminations | Termination Reason | Insert | | | | 1/6/2015 12:43 PM |