Healthcare Provider Details

I. General information

NPI: 1356331615
Provider Name (Legal Business Name): LAKE SHASTINA MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16337 EVERHART DR
WEED CA
96094-9400
US

IV. Provider business mailing address

16337 EVERHART DR
WEED CA
96094-9400
US

V. Phone/Fax

Practice location:
  • Phone: 530-938-2297
  • Fax: 530-938-0494
Mailing address:
  • Phone: 530-938-2297
  • Fax: 530-938-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP M MILLER
Title or Position: CEO
Credential: M.D.
Phone: 530-938-2297