Healthcare Provider Details

I. General information

NPI: 1245249770
Provider Name (Legal Business Name): SHASTA CRITICAL CARE SPECIALISTS MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 OLD EUREKA WAY SUITE 1E
REDDING CA
96001-0228
US

IV. Provider business mailing address

2701 OLD EUREKA WAY STE 1E
REDDING CA
96001-0228
US

V. Phone/Fax

Practice location:
  • Phone: 530-232-3000
  • Fax: 530-232-3099
Mailing address:
  • Phone: 530-232-3000
  • Fax: 530-242-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: RAFAEL LUPERCIO
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 530-232-3000