Basic Information
| Provider Information | |||||||||
| NPI: | 1447287347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUMBOLDT FAMILY MEDICAL CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 4957 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955184957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078227220 | ||||||||
| FaxNumber: | 7078268258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1733 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MCKINLEYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955193601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078394852 | ||||||||
| FaxNumber: | 7078392439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7078227220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 05-8505 | 01 | CA | BLUE CROSS PROVIDER # | OTHER | ZZZ67827Z | 01 | CA | BLUE SHEIRLD PROVIDER # | OTHER | RHM53803G | 05 | CA | MEDICAID |