Healthcare Provider Details

I. General information

NPI: 1467937367
Provider Name (Legal Business Name): QUAILHEARST CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 PARK MARINA DR STE A
REDDING CA
96001-2840
US

IV. Provider business mailing address

PO BOX 71076
SHASTA LAKE CA
96079-1076
US

V. Phone/Fax

Practice location:
  • Phone: 530-949-8221
  • Fax:
Mailing address:
  • Phone: 530-949-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNNI MILLER
Title or Position: PRESIDENT
Credential: RDH
Phone: 530-949-8221