Provider Demographics
NPI:1285000810
Name:LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC.
Entity Type:Organization
Organization Name:LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-263-8382
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8382
Mailing Address - Fax:
Practice Address - Street 1:14678 LAKESHORE BOULEVARD
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95453
Practice Address - Country:US
Practice Address - Phone:707-262-8382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)