Basic Information
| Provider Information | |||||||||
| NPI: | 1356331615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE SHASTINA MEDICAL CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16337 EVERHART DR | ||||||||
| Address2: | |||||||||
| City: | WEED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960949400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309382297 | ||||||||
| FaxNumber: | 5309380494 | ||||||||
| Practice Location | |||||||||
| Address1: | 16337 EVERHART DR | ||||||||
| Address2: | |||||||||
| City: | WEED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960949400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309382297 | ||||||||
| FaxNumber: | 5309380494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5309382297 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0098510 | 05 | CA | MEDICAID |