1922020585 NPI number — MENDOCINO COMMUNITY HEALTH CLINIC, INC.

Table of content: (NPI 1922020585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922020585 NPI number — MENDOCINO COMMUNITY HEALTH CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDOCINO COMMUNITY HEALTH 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:
LITTLE LAKE HEALTH CENTER
Provider Other Organization Name Type Code:
5
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:
1922020585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 LAWS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UKIAH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95482-6540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-468-1010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 HAZEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLITS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-456-9600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOLAN
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
707-467-2260

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  110000500 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HAP70968F . This is a "FAMILYPACT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70968F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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