Provider Demographics
NPI:1417542606
Name:FAIRCHILD MEDICAL CLINIC
Entity Type:Organization
Organization Name:FAIRCHILD MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:530-842-3507
Mailing Address - Street 1:475 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3474
Mailing Address - Country:US
Mailing Address - Phone:530-842-3507
Mailing Address - Fax:
Practice Address - Street 1:475 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3474
Practice Address - Country:US
Practice Address - Phone:530-842-3507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRCHILD MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336330646Medicaid