Provider Demographics
NPI:1326146333
Name:LAST FRONTIER HEALTHCARE DISTRICT
Entity Type:Organization
Organization Name:LAST FRONTIER HEALTHCARE DISTRICT
Other - Org Name:MODOC MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALT
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:530-233-5883
Mailing Address - Street 1:228 W MCDOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-3934
Mailing Address - Country:US
Mailing Address - Phone:530-233-5131
Mailing Address - Fax:530-233-6609
Practice Address - Street 1:225 W MCDOWELL AVE
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101-3933
Practice Address - Country:US
Practice Address - Phone:530-233-3416
Practice Address - Fax:530-233-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55420FMedicaid
CALTC55420FMedicaid
CA555420Medicare Oscar/Certification
CAZZZ93342ZMedicare PIN