| |
14092 Lakeshore Dr Clearlake CA 95422-8160 | |
(707) 994-4261 | |
Not Available |
Full Name | |
---|---|
Speciality | Community/behavioral Health |
Location | 14092 Lakeshore Dr, Clearlake, California |
Authorized Official Name and Position | Elise Jones Ma (DIRECTOR) |
Authorized Official Contact | 7072749101 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
Po Box 1024 Lucerne CA 95458-1024 Ph: (707) 994-4261 | 14092 Lakeshore Dr Clearlake CA 95422-8160 Ph: (707) 994-4261 |
NPI Number | 1356181127 |
---|---|
Provider Enumeration Date | 05/29/2024 |
Last Update Date | 08/26/2024 |
Certification Date | 08/26/2024 |
Identifier | Type | State | Issuer |
---|---|---|---|
1356181127 | NPI | - | NPPES |
17E1 | Medicaid | CA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |