Provider Demographics
NPI:1770516304
Name:MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Entity type:Organization
Organization Name:MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-467-2260
Mailing Address - Street 1:333 LAWS AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6540
Mailing Address - Country:US
Mailing Address - Phone:707-468-1010
Mailing Address - Fax:
Practice Address - Street 1:5335 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6123
Practice Address - Country:US
Practice Address - Phone:707-263-7725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000350261Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70845FOtherFAMILYPACT
CAFHC70845FMedicaid
CAZZZ23172ZMedicare ID - Type Unspecified
CAFHC70845FMedicaid
CAZZZ18787ZMedicare Oscar/Certification