Basic Information
| Provider Information | |||||||||
| NPI: | 1336150051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEASTERN RURAL HEALTH CLINICS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTWOOD FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302511427 | ||||||||
| FaxNumber: | 5302521340 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 BIRCH STREET | ||||||||
| Address2: | |||||||||
| City: | WESTWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302563152 | ||||||||
| FaxNumber: | 5302562061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHAUB | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5302511424 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHEASTERN RURAL HEALTH CLINICS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FHC70292F | 05 | CA | MEDICAID | ZZZ95961Z | 01 | CA | BLUE SHIELD | OTHER |