Provider Demographics
NPI:1164680823
Name:MCCLOUD DBA UROLOGY CLINIC
Entity type:Organization
Organization Name:MCCLOUD DBA UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:VELTKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-924-0244
Mailing Address - Street 1:830 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2137
Mailing Address - Country:US
Mailing Address - Phone:530-926-3891
Mailing Address - Fax:
Practice Address - Street 1:830 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2137
Practice Address - Country:US
Practice Address - Phone:530-926-3891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCCLOUD HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21996174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty