Healthcare Provider Details

I. General information

NPI: 1922020585
Provider Name (Legal Business Name): MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 HAZEL ST
WILLITS CA
95490
US

IV. Provider business mailing address

333 LAWS AVE
UKIAH CA
95482-6540
US

V. Phone/Fax

Practice location:
  • Phone: 707-456-9600
  • Fax:
Mailing address:
  • Phone: 707-468-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number110000500
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM DOLAN
Title or Position: CFO
Credential:
Phone: 707-467-2260