Provider Demographics
NPI:1063158038
Name:LAKE COUNTY TRIBAL HEALTH SOUTHSHORE CLINIC
Entity type:Organization
Organization Name:LAKE COUNTY TRIBAL HEALTH SOUTHSHORE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-263-8382
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8382
Mailing Address - Fax:
Practice Address - Street 1:14440 OLYMPIC DRIVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:707-263-5019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE COUNTY TRIBAL HEALTH CONSORTIUM INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-11
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)