Provider Demographics
NPI:1922020585
Name:MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:LITTLE LAKE HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-467-2260
Mailing Address - Street 1:333 LAWS AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6540
Mailing Address - Country:US
Mailing Address - Phone:707-468-1010
Mailing Address - Fax:
Practice Address - Street 1:45 HAZEL ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490
Practice Address - Country:US
Practice Address - Phone:707-456-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000500261Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70968FOtherFAMILYPACT
CAFHC70968FMedicaid
CAZZZ23182ZMedicare Oscar/Certification
CAFHC70968FMedicaid
CAZZZ27031ZMedicare Oscar/Certification