Provider Demographics
NPI: | 1164680823 |
---|---|
Name: | MCCLOUD DBA UROLOGY CLINIC |
Entity Type: | Organization |
Organization Name: | MCCLOUD DBA UROLOGY CLINIC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ENROLLMENT |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | ROBIN |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | VELTKAMP |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 231-924-0244 |
Mailing Address - Street 1: | 830 PINE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MOUNT SHASTA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 96067-2137 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 530-926-3891 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 830 PINE ST |
Practice Address - Street 2: | |
Practice Address - City: | MOUNT SHASTA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 96067-2137 |
Practice Address - Country: | US |
Practice Address - Phone: | 530-926-3891 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | MCCLOUD HEALTH CENTER |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2008-05-29 |
Last Update Date: | 2008-05-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A21996 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |