Provider Demographics
NPI:1952526444
Name:PLACER COUNTY COMMUNITY CLINIC
Entity Type:Organization
Organization Name:PLACER COUNTY COMMUNITY CLINIC
Other - Org Name:PLACER DENTAL CLINIC TAHOE
Other - Org Type:Other Name
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:PO BOX 1785
Mailing Address - Street 2:
Mailing Address - City:KINGS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:96143-1785
Mailing Address - Country:US
Mailing Address - Phone:530-546-1970
Mailing Address - Fax:530-546-4606
Practice Address - Street 1:8665 SALMON AVE
Practice Address - Street 2:
Practice Address - City:KINGS BEACH
Practice Address - State:CA
Practice Address - Zip Code:96143-9800
Practice Address - Country:US
Practice Address - Phone:530-546-1970
Practice Address - Fax:530-546-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9260102Medicaid