Healthcare Provider Details

I. General information

NPI: 1376669481
Provider Name (Legal Business Name): REDDING PRIMARY CARE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/16/2021
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 HILLTOP DR
REDDING CA
96003-3811
US

IV. Provider business mailing address

1093 HILLTOP DR
REDDING CA
96003-3811
US

V. Phone/Fax

Practice location:
  • Phone: 530-221-1565
  • Fax: 530-221-3912
Mailing address:
  • Phone: 530-221-1565
  • Fax: 530-221-3912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberBUSS LIC# 23151
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LINDA YVONNE FULLERTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 530-221-1565