Provider Demographics
NPI:1376570473
Name:WILLOW CREEK - SIX RIVERS MEDICAL CENTER
Entity Type:Organization
Organization Name:WILLOW CREEK - SIX RIVERS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-822-7220
Mailing Address - Street 1:P.O. BOX 4388
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95518-4388
Mailing Address - Country:US
Mailing Address - Phone:707-822-7220
Mailing Address - Fax:707-826-8258
Practice Address - Street 1:850 STATE HWY 96
Practice Address - Street 2:
Practice Address - City:WILLOW CREEK
Practice Address - State:CA
Practice Address - Zip Code:95573
Practice Address - Country:US
Practice Address - Phone:530-629-3777
Practice Address - Fax:530-629-2866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-3980OtherBLUE CROSS PROVIDER #
CARHM10028FMedicaid
CAZZZ33943ZOtherBLUE SHIELD PROVIDER #
CAHAP10028FOtherFAMILY PACT PROVIDER #
CA55-3980Medicare ID - Type Unspecified