Basic Information
Provider Information | |||||||||
NPI: | 1952328403 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHASTA COMMUNITY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTH OUTREACH FOR PEOPLE EVERYWHERE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 992790 | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960992790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302465710 | ||||||||
FaxNumber: | 5302417838 | ||||||||
Practice Location | |||||||||
Address1: | 1035 PLACER ST | ||||||||
Address2: |   | ||||||||
City: | REDDING | ||||||||
State: | CA | ||||||||
PostalCode: | 960011125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302465710 | ||||||||
FaxNumber: | 5302417838 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 04/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GERMANO | ||||||||
AuthorizedOfficialFirstName: | DEAN | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5602465726 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 230000171 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 207Q00000X | 230000171 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | FHC70418F | 01 | CA | SCHC-HOPE MEDI-CAL NUMBER | OTHER |