Healthcare Provider Details

I. General information

NPI: 1457059768
Provider Name (Legal Business Name): MCCLOUD HEALTHCARE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4303 STAGECOACH RD
DUNSMUIR CA
96025-1812
US

IV. Provider business mailing address

PO BOX 1143
MCCLOUD CA
96057-1143
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-6309
  • Fax:
Mailing address:
  • Phone: 530-964-2389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MR. CALEB OTT
Title or Position: CEO
Credential:
Phone: 530-926-6309