Provider Demographics
NPI:1316966302
Name:REDDING PRIMARY CARE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:REDDING PRIMARY CARE MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-221-1565
Mailing Address - Street 1:1093 HILLTOP DRIVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-3811
Mailing Address - Country:US
Mailing Address - Phone:530-221-1565
Mailing Address - Fax:530-221-3912
Practice Address - Street 1:1093 HILLTOP DRIVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-3811
Practice Address - Country:US
Practice Address - Phone:530-221-1565
Practice Address - Fax:530-221-3912
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REDDING PRIMARY CARE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-19
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABUSS LIC #9113261QU0200X
CAG63898207Q00000X
CAG70179207Q00000X
CAA86612207Q00000X
CAG42236207R00000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0618250OtherCLIA #
CAZZZ11432ZMedicare PIN
CA05D0618250OtherCLIA #