NPIMap

Organization Active NPI

Shasta Community Health Center

Doing business as Shasta Lake Family Health & Dental Center

  • Federally Qualified Health Center (FQHC)
  • Shasta Lake, CA
National Provider Identifier
1013932797
Registry record updated Oct 16, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SHASTA COMMUNITY HEALTH CENTER
Doing business as
Shasta Lake Family Health & Dental Center
Practice address
4215 Front St
Shasta Lake, CA 96019-9430
Phone
(530) 246-5896
Fax
(530) 241-7838
NPI assigned
Jul 13, 2006
Last updated
Oct 16, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SHASTA COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 16, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jeffery Brandon Thornock
Title
Ceo
Phone
(530) 246-5074

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Medical Physician Assistant 363AM0700X 230000325 CA
Family Nurse Practitioner 363LF0000X 230000325 CA
Dentist 122300000X 230000325 CA
Family Medicine Physician 207Q00000X 230000325 CA

Addresses

Primary practice location

4215 Front St
Shasta Lake, CA 96019-9430

Mailing address

PO Box 992790
Redding, CA 96099-2790
Phone (530) 246-5896

Other identifiers 1

IdentifierTypeStateIssuer
FHC70877FOtherCASCHC-SLC MEDI-CAL NUMBER

Other names 1

  • Shasta Lake Family Health & Dental Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040629000721 CA Part B Supplier - Clinic/Group Practice 3870579816 Receives reassigned benefits from 156 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Anderson, CA; Redding, CA; Shasta Lake, CA
O20100625000635 CA Part A Provider - Federally Qualified Health Center (FQHC) 3870579816 Practice locations: Shasta Lake, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013932797. Details of each certification follow.

Federally qualified health center certification: CCN 551888

Legal name
SHASTA COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 20, 2001
Last certification
Apr 20, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 7, 1988 in CA
Enrollment address
4215 Front St
Shasta Lake, CA 96019-9430

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Shasta Community HLTH Ctr

Locations

1201 Industrial St
Redding, CA 96002
Phone (530) 229-5000

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Laura Baynard Individual Corporate OfficerChief Operations Officer Mar 3, 2024
W-2 Managing EmployeeChief Operations Officer Mar 3, 2024
Stephen Bell Individual Corporate DirectorConsumer Member Jan 26, 2024
Christy Coleman Individual Corporate DirectorCommunity Member Apr 27, 2023
Daniel Santi Individual Corporate OfficerChief Financial Officer Aug 24, 2023
W-2 Managing EmployeeChief Financial Officer Aug 24, 2023
Michael Mangas Individual Corporate Director Jul 25, 2019
Robert Folden Individual Corporate DirectorProvider Member Dec 13, 2021
Wendy Longwell Individual Corporate DirectorTreasurer Jun 25, 2014
Casey Fatch Individual Corporate DirectorProvider Member Sep 28, 2023
John Kenny Individual Corporate DirectorVice Chair Apr 22, 2013
Samantha Breton Individual Corporate DirectorConsumer Member Oct 27, 2022
Kerry Fasking Individual Corporate DirectorChair Jul 24, 2013
Brandon Thornock Individual Corporate OfficerChief Executive Officer Oct 1, 2017
W-2 Managing EmployeeChief Executive Officer Oct 1, 2017
Margaret Beck Individual Corporate DirectorSecretary Feb 23, 2017
Dot Van Cleave Individual Corporate Director Sep 28, 2017

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729036800000",
    "number": "1013932797",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 992790",
            "city": "REDDING",
            "state": "CA",
            "postal_code": "960992790",
            "telephone_number": "530-246-5896",
            "fax_number": "530-241-7836"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4215 FRONT ST",
            "city": "SHASTA LAKE",
            "state": "CA",
            "postal_code": "960199430",
            "telephone_number": "530-246-5896",
            "fax_number": "530-241-7838"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHASTA COMMUNITY HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SHASTA COMMUNITY HEALTH CENTER",
        "enumeration_date": "2006-07-13",
        "last_updated": "2024-10-16",
        "certification_date": "2024-10-16",
        "status": "A",
        "authorized_official_last_name": "THORNOCK",
        "authorized_official_first_name": "JEFFERY",
        "authorized_official_middle_name": "BRANDON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "530-246-5074",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "CA",
            "license": "230000325",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "CA",
            "license": "230000325",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "CA",
            "license": "230000325",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CA",
            "license": "230000325",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SCHC-SLC MEDI-CAL NUMBER",
            "identifier": "FHC70877F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shasta Lake Family Health & Dental Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shasta Lake, CA

Sources for this page

Verify at the official NPI Registry.