Provider Demographics
NPI:1538181557
Name:SHASTA COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:SHASTA COMMUNITY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:THORNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-246-5710
Mailing Address - Street 1:PO BOX 992790
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-2790
Mailing Address - Country:US
Mailing Address - Phone:530-246-5894
Mailing Address - Fax:530-241-7838
Practice Address - Street 1:1201 INDUSTRIAL ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0757
Practice Address - Country:US
Practice Address - Phone:530-246-5894
Practice Address - Fax:530-241-7838
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHASTA COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000297122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70840FOtherSCHCDENTAL MEDI-CAL NO