=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275539793
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LASSEN INDIAN HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2005
-----------------------------------------------------
Last Update Date | 12/31/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 795 JOAQUIN ST
-----------------------------------------------------
City | SUSANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96130-3628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-257-2542
-----------------------------------------------------
Fax | 530-251-5208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 795 JOAQUIN ST
-----------------------------------------------------
City | SUSANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-257-2542
-----------------------------------------------------
Fax | 530-251-5208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGER
-----------------------------------------------------
Name | MRS. DEBRA SOKOL
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 530-257-2542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | RN300870
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------