Provider Demographics
NPI:1063547131
Name:SHASTA COUNTY PUBLIC HEALTH LABORATORY
Entity type:Organization
Organization Name:SHASTA COUNTY PUBLIC HEALTH LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PUBLIC HEALTH
Authorized Official - Prefix:MR
Authorized Official - First Name:DONNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:EWERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-245-6296
Mailing Address - Street 1:2650 BRESLAUER WAY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-4246
Mailing Address - Country:US
Mailing Address - Phone:530-225-5072
Mailing Address - Fax:
Practice Address - Street 1:2650 BRESLAUER WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-4246
Practice Address - Country:US
Practice Address - Phone:530-225-5072
Practice Address - Fax:530-225-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58363FMedicaid
CALAB58363FMedicaid