Provider Demographics
NPI:1013932797
Name:SHASTA COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SHASTA COMMUNITY HEALTH CENTER
Other - Org Name:SHASTA LAKE CITY FAMILY HEALTH CENTER/DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-246-5074
Mailing Address - Street 1:PO BOX 992790
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-2790
Mailing Address - Country:US
Mailing Address - Phone:530-246-5896
Mailing Address - Fax:530-241-7836
Practice Address - Street 1:4215 FRONT ST
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9430
Practice Address - Country:US
Practice Address - Phone:530-246-5896
Practice Address - Fax:530-241-7838
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHASTA COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000325122300000X, 207Q00000X, 363AM0700X, 363LF0000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70877FOtherSCHC-SLC MEDI-CAL NUMBER
CAFHC70877FOtherSCHC-SLC MEDI-CAL NUMBER