Basic Information
| Provider Information | |||||||||
| NPI: | 1942225719 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHASTA COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANDERSON FAMILY HEALTH/DENTAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 992790 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960992790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303780486 | ||||||||
| FaxNumber: | 5302417838 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 SILVER ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960074239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303780486 | ||||||||
| FaxNumber: | 5302417838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 01/08/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GERMANO | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5302465726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHASTA COMMUNITY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 230000287 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 363A00000X | 230000287 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | 230000287 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 230000287 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FHC70765F | 01 | CA | SCHC-ANDY MEDI-CAL NUMBER | OTHER |