Basic Information
| Provider Information | |||||||||
| NPI: | 1679514483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT SHASTA MEDI-CAL CLINIC, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALPINE HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 912 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265105 | ||||||||
| FaxNumber: | 5309261359 | ||||||||
| Practice Location | |||||||||
| Address1: | 912 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265105 | ||||||||
| FaxNumber: | 5309261359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/04/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAYLESS | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5309265105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CMPE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 230000075 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | EAP53856F | 01 | CA | EAP | OTHER | RHM53856F | 05 | CA | MEDICAID |