Basic Information
| Provider Information | |||||||||
| NPI: | 1376893420 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCLOUD HEALTHCARE CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DUNSMUIR COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1143 | ||||||||
| Address2: | |||||||||
| City: | MCCLOUD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960571143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309642389 | ||||||||
| FaxNumber: | 5309643141 | ||||||||
| Practice Location | |||||||||
| Address1: | 4309 STAGECOACH ROAD | ||||||||
| Address2: | |||||||||
| City: | DUNSMUIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302354138 | ||||||||
| FaxNumber: | 5303782453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHUB | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5309642389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | G32096 | 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 | 00G320960 | 05 | CA | MEDICAID |