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General NPI Number Information
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NPI Number | 1982418430
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Entity Type | Organization
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Legal Business Name | LAKE COUNTY TRIBAL HEALTH MIDDLETOWN CLINIC
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Dates
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Enumeration Date | 02/05/2025
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 22223 CA-29 RANCHERIA ROAD, TRIBAL OFFICES #1035
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City | MIDDLETOWN
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State | CA
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Zip | 95461
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Country | US
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Telephone | 707-263-8382
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1950
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City | LAKEPORT
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State | CA
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Zip | 95453-1950
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EHR SPECIALIST
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Name | THOMAS BURNETT
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Credential |
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Telephone | 707-263-8382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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