Provider Demographics
NPI:1740945906
Name:SHASTA PRIMARY CARE LLC
Entity type:Organization
Organization Name:SHASTA PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RENDERING PROVIDER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNI
Authorized Official - Middle Name:VONICE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:530-949-7860
Mailing Address - Street 1:2121 AIRPARK DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2433
Mailing Address - Country:US
Mailing Address - Phone:530-255-8025
Mailing Address - Fax:530-255-8028
Practice Address - Street 1:2121 AIRPARK DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2433
Practice Address - Country:US
Practice Address - Phone:530-255-8025
Practice Address - Fax:530-255-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-03
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA202129410899OtherSTATE FILE NUMBER
CA1000694320Medicaid
CACA376666Medicaid