Provider Demographics
NPI:1588048680
Name:SHASTA REGIONAL MEDICAL GROUP, INC
Entity type:Organization
Organization Name:SHASTA REGIONAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:ELAINA
Authorized Official - Last Name:CUTLIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-605-4263
Mailing Address - Street 1:50 ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:WEED
Mailing Address - State:CA
Mailing Address - Zip Code:96094-2352
Mailing Address - Country:US
Mailing Address - Phone:530-605-4263
Mailing Address - Fax:
Practice Address - Street 1:50 ALAMO AVE
Practice Address - Street 2:
Practice Address - City:WEED
Practice Address - State:CA
Practice Address - Zip Code:96094-2352
Practice Address - Country:US
Practice Address - Phone:530-605-4263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHASTA REGIONAL MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-17
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty