Healthcare Provider Details

I. General information

NPI: 1679293443
Provider Name (Legal Business Name): CCMMA CA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BUTTE ST
REDDING CA
96001-0852
US

IV. Provider business mailing address

PO BOX 631917
CINCINNATI OH
45263-1917
US

V. Phone/Fax

Practice location:
  • Phone: 530-244-5400
  • Fax: 888-220-6560
Mailing address:
  • Phone: 845-702-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURIE LADUCA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 845-702-2711