1376893420 NPI number — MCCLOUD HEALTHCARE CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376893420 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:
DUNSMUIR COMMUNITY HEALTH CENTER
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:
1376893420
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:
4309 STAGECOACH ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNSMUIR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-235-4138
Provider Business Practice Location Address Fax Number:
530-378-2453
Provider Enumeration Date:
09/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
OTT
Authorized Official First Name:
CALEB
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
530-964-2389

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: G32096 , 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: 00G320960 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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