Provider Demographics
NPI:1083783757
Name:MENDOCINO COAST CLINICS INC
Entity Type:Organization
Organization Name:MENDOCINO COAST CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCRESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENTERIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-964-1251
Mailing Address - Street 1:205 SOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5540
Mailing Address - Country:US
Mailing Address - Phone:707-964-1251
Mailing Address - Fax:707-961-2722
Practice Address - Street 1:205 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5540
Practice Address - Country:US
Practice Address - Phone:707-964-1251
Practice Address - Fax:707-961-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03967FMedicaid
CAZZZ15984ZOtherMEDICARE PART B PTAN
CAFHC03967FMedicaid
CA55-1813Medicare UPIN