Provider Demographics
NPI:1679514483
Name:MT SHASTA MEDI-CAL CLINIC, INC
Entity Type:Organization
Organization Name:MT SHASTA MEDI-CAL CLINIC, INC
Other - Org Name:ALPINE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYLESS
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:530-926-5105
Mailing Address - Street 1:912 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2143
Mailing Address - Country:US
Mailing Address - Phone:530-926-5105
Mailing Address - Fax:530-926-1359
Practice Address - Street 1:912 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-5105
Practice Address - Fax:530-926-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000075261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP53856FOtherEAP
CARHM53856FMedicaid
CARHM53856FMedicaid