1164428488 NPI number — MCCLOUD HEALTHCARE CLINIC, INC.

Table of content: (NPI 1164428488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164428488 NPI number — MCCLOUD HEALTHCARE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCCLOUD HEALTHCARE CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHASTA CASCADE HEALTH CENTERS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164428488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCLOUD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96057-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-964-2389
Provider Business Mailing Address Fax Number:
530-964-3141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 W MINNESOTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCLOUD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96057-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-964-2389
Provider Business Practice Location Address Fax Number:
530-964-3141
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OTT
Authorized Official First Name:
CALEB
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
530-926-6309

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  550001195 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X , with the licence number: 553934 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ24754Z . This is a "MEDICARE PART B" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: RHM53934F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ24754Z . This is a "BCBS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 55-3934 . This is a "CAHABA GBA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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