Provider Demographics
NPI:1376609198
Name:LUCERNE COMMUNITY CLINIC
Entity Type:Organization
Organization Name:LUCERNE COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-274-9299
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458-1978
Mailing Address - Country:US
Mailing Address - Phone:707-274-9299
Mailing Address - Fax:707-274-9297
Practice Address - Street 1:6300 E. HWY 20
Practice Address - Street 2:
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458
Practice Address - Country:US
Practice Address - Phone:707-274-9299
Practice Address - Fax:707-274-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53967FMedicaid
CA553967Medicare ID - Type Unspecified