Healthcare Provider Details

I. General information

NPI: 1164428488
Provider Name (Legal Business Name): MCCLOUD HEALTHCARE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W MINNESOTA AVE
MCCLOUD CA
96057-1143
US

IV. Provider business mailing address

PO BOX 1143
MCCLOUD CA
96057-1143
US

V. Phone/Fax

Practice location:
  • Phone: 530-964-2389
  • Fax: 530-964-3141
Mailing address:
  • Phone: 530-964-2389
  • Fax: 530-964-3141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number553934
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550001195
License Number StateCA

VIII. Authorized Official

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