Healthcare Provider Details

I. General information

NPI: 1376609198
Provider Name (Legal Business Name): LUCERNE COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 E. HWY 20
LUCERNE CA
95458
US

IV. Provider business mailing address

PO BOX 1978
LUCERNE CA
95458-1978
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9299
  • Fax: 707-274-9297
Mailing address:
  • Phone: 707-274-9299
  • Fax: 707-274-9297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT WILLIAM GARDNER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 707-274-9299