Provider Demographics
NPI:1164428488
Name:MCCLOUD HEALTHCARE CLINIC, INC.
Entity Type:Organization
Organization Name:MCCLOUD HEALTHCARE CLINIC, INC.
Other - Org Name:SHASTA CASCADE HEALTH CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:J
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-926-6309
Mailing Address - Street 1:PO BOX 1143
Mailing Address - Street 2:
Mailing Address - City:MCCLOUD
Mailing Address - State:CA
Mailing Address - Zip Code:96057-1143
Mailing Address - Country:US
Mailing Address - Phone:530-964-2389
Mailing Address - Fax:530-964-3141
Practice Address - Street 1:116 W MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:MCCLOUD
Practice Address - State:CA
Practice Address - Zip Code:96057-1143
Practice Address - Country:US
Practice Address - Phone:530-964-2389
Practice Address - Fax:530-964-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001195261QF0400X
CA553934261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24754ZOtherMEDICARE PART B
CARHM53934FMedicaid
CAZZZ24754ZOtherBCBS
CA55-3934OtherCAHABA GBA
CA051168Medicare Oscar/Certification