Provider Demographics
NPI:1033320726
Name:SHASTA COMMUNITY COLLEGE - STUDENT HEALTH SERVICES
Entity Type:Organization
Organization Name:SHASTA COMMUNITY COLLEGE - STUDENT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTED PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-242-7580
Mailing Address - Street 1:11555 OLD OREGON TRL
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-7692
Mailing Address - Country:US
Mailing Address - Phone:530-242-7580
Mailing Address - Fax:530-225-4968
Practice Address - Street 1:11555 OLD OREGON TRL
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-7692
Practice Address - Country:US
Practice Address - Phone:530-242-7580
Practice Address - Fax:530-225-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45631261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health