Healthcare Provider Details

I. General information

NPI: 1528402336
Provider Name (Legal Business Name): LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/25/2013
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: 707-263-3790
Mailing address:
  • Phone: 707-263-8382
  • Fax: 707-263-3790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number51235
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number51235
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number51235
License Number StateCA

VIII. Authorized Official

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