Healthcare Provider Details

I. General information

NPI: 1881697381
Provider Name (Legal Business Name): LAKE COUNTY TRIBAL HEALTH CONSORTIUM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BEVINS CT
LAKEPORT CA
95453-9754
US

IV. Provider business mailing address

925 BEVINS CT
LAKEPORT CA
95453-9754
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-8382
  • Fax: 707-263-0329
Mailing address:
  • Phone: 707-263-8382
  • Fax: 707-263-0329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number110000289
License Number StateCA

VIII. Authorized Official

Name: MR. ERNESTO PADILLA JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 707-263-8382