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General NPI Number Information
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NPI Number | 1679514483
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Entity Type | Organization
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Legal Business Name | MT SHASTA MEDI-CAL CLINIC, INC
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Dates
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Enumeration Date | 06/10/2006
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Last Update Date | 08/04/2009
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Provider Practice Location Address
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Address Line | 912 PINE ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067-2143
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Country | US
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Telephone | 530-926-5105
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Fax | 530-926-1359
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Provider Business Mailing Address
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Address Line | 912 PINE ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067-2143
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Country | US
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Telephone | 530-926-5105
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Fax | 530-926-1359
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | CHRIS BAYLESS
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Credential | CMPE
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Telephone | 530-926-5105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 230000075
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License Number State | CA
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