Basic Information
| Provider Information | |||||||||
| NPI: | 1477563518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEASTERN RURAL HEALTH CLINICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302515000 | ||||||||
| FaxNumber: | 5302576015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302515000 | ||||||||
| FaxNumber: | 5302576015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHAUB | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5302511428 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHEASTERN HEALTH CENTER | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
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 | ZZZ87615Z | 01 | BLUE SHIELD | OTHER | 080005169 | 01 | RRMCR DOZIER | OTHER | 080042465 | 01 | RRMCR HOLMES | OTHER | 080119610 | 01 | RRMCR DAVAINIS | OTHER | 080061921 | 01 | RRMCR MORGAN | OTHER | FHC70081F | 05 | CA | MEDICAID |