Provider Demographics
NPI:1376669481
Name:REDDING PRIMARY CARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:REDDING PRIMARY CARE MEDICAL GROUP, INC
Other - Org Name:HILLTOP MEDICAL CLINIC WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-221-1565
Mailing Address - Street 1:1093 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-3811
Mailing Address - Country:US
Mailing Address - Phone:530-221-1565
Mailing Address - Fax:530-221-3912
Practice Address - Street 1:1093 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-3811
Practice Address - Country:US
Practice Address - Phone:530-221-1565
Practice Address - Fax:530-221-3912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABUSS LIC# 23151261Q00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1064577OtherMEDICARE CLIA NUMBER
CAZZZ11432ZOtherMEDICARE PTAN
CA05D1064577OtherMEDICARE CLIA NUMBER
CAZZZ11432ZOtherMEDICARE PTAN