Basic Information
| Provider Information | |||||||||
| NPI: | 1164428488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCCLOUD HEALTHCARE CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1143 | ||||||||
| Address2: | |||||||||
| City: | MCCLOUD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960571143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309642389 | ||||||||
| FaxNumber: | 5309643141 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 W MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | MCCLOUD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960571143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309642389 | ||||||||
| FaxNumber: | 5309643141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | MALONE | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5309642389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 553934 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QF0400X | 550001195 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | RHM53934F | 05 | CA | MEDICAID | ZZZ24754Z | 01 | CA | MEDICARE PART B | OTHER | 55-3934 | 01 | CA | CAHABA GBA | OTHER | ZZZ24754Z | 01 | CA | BCBS | OTHER |