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912 Pine St Mount Shasta CA 96067-2143 | |
| (530) 926-5105 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 912 Pine St, Mount Shasta, California |
| Authorized Official Name and Position | Kim Miranda (CHIEF FINANCIAL OFFICER) |
| Authorized Official Contact | 5302256121 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
3400 Data Dr 1st Floor Rancho Cordova CA 95670-7956 Ph: (530) 225-6300 | 912 Pine St Mount Shasta CA 96067-2143 Ph: (530) 926-5105 |
| NPI Number | 1568799500 |
|---|---|
| Provider Enumeration Date | 11/12/2009 |
| Last Update Date | 10/31/2016 |
| Medicare PECOS PAC ID | 2062320559 |
|---|---|
| Medicare Enrollment ID | O20091216000383 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1568799500 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QR1300X | Clinic/center - Rural Health | (* (Not Available)) | Primary |
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