Provider Demographics
NPI:1982418430
Name:LAKE COUNTY TRIBAL HEALTH MIDDLETOWN CLINIC
Entity type:Organization
Organization Name:LAKE COUNTY TRIBAL HEALTH MIDDLETOWN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EHR SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
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:
Mailing Address - Fax:
Practice Address - Street 1:22223 CA-29
Practice Address - Street 2:RANCHERIA ROAD, TRIBAL OFFICES #1035
Practice Address - City:MIDDLETOWN
Practice Address - State:CA
Practice Address - Zip Code:95461
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE COUNTY TRIBAL HEALTH CONSORTIUM INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)