Provider Demographics
NPI:1205952157
Name:PLACER COUNTY COMMUNITY CLINIC
Entity type:Organization
Organization Name:PLACER COUNTY COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-886-2910
Mailing Address - Street 1:11583 C AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2703
Mailing Address - Country:US
Mailing Address - Phone:530-889-7215
Mailing Address - Fax:530-889-7280
Practice Address - Street 1:11526 C AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2704
Practice Address - Country:US
Practice Address - Phone:530-889-7188
Practice Address - Fax:530-889-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92601-01Medicaid