Provider Demographics
NPI:1326335464
Name:MENDOCINO COAST CLINICS, INC
Entity Type:Organization
Organization Name:MENDOCINO COAST CLINICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LUCRESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENTERIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-964-1251
Mailing Address - Street 1:205 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5540
Mailing Address - Country:US
Mailing Address - Phone:707-964-1251
Mailing Address - Fax:707-961-2653
Practice Address - Street 1:510 CYPRESS ST STE D
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-964-5696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MENDOCINO COAST CLINICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-08
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)