Basic Information
| Provider Information | |||||||||
| NPI: | 1003372624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCCLOUD HEALTHCARE CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1143 | ||||||||
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| City: | MCCLOUD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960571143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309642389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 828 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309264528 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2019 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | PROFFITT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5309642389 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCLOUD HEALTHCARE CLINIC, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471B0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry |
No ID Information.