Provider Demographics
NPI:1144770793
Name:WESTERN SIERRA MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:WESTERN SIERRA MEDICAL CLINIC, INC.
Other - Org Name:WESTERN SIERRA MEDICAL CLINIC - LOCKSLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PLANNING AND DEVELOPMENT OFFI
Authorized Official - Prefix:
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-273-4984
Mailing Address - Street 1:844 OLD TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8524
Mailing Address - Country:US
Mailing Address - Phone:530-274-9762
Mailing Address - Fax:530-273-4573
Practice Address - Street 1:12183 LOCKSLEY LN STE 107
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602
Practice Address - Country:US
Practice Address - Phone:530-273-4984
Practice Address - Fax:530-273-4573
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN SIERRA MEDICAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-06
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000145261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851513469OtherPARENT NPI