Provider Demographics
NPI:1205089026
Name:PRIME HEALTHCARE SERVICES - SHASTA LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES - SHASTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-235-4307
Mailing Address - Street 1:12479 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2670
Mailing Address - Country:US
Mailing Address - Phone:909-464-8896
Mailing Address - Fax:909-464-8887
Practice Address - Street 1:1100 BUTTE ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0852
Practice Address - Country:US
Practice Address - Phone:530-244-8303
Practice Address - Fax:530-229-2811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000023282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050764Medicare Oscar/Certification