Healthcare Provider Details

I. General information

NPI: 1982418430
Provider Name (Legal Business Name): LAKE COUNTY TRIBAL HEALTH MIDDLETOWN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22223 CA-29 RANCHERIA ROAD, TRIBAL OFFICES #1035
MIDDLETOWN CA
95461
US

IV. Provider business mailing address

PO BOX 1950
LAKEPORT CA
95453-1950
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: THOMAS BURNETT
Title or Position: EHR SPECIALIST
Credential:
Phone: 707-263-8382