NPIMap

Organization Active NPI

McCloud Healthcare Clinic, Inc.

Doing business as Shasta Cascade Health Centers

  • Federally Qualified Health Center (FQHC)
  • McCloud, CA
National Provider Identifier
1164428488
Registry record updated Mar 23, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
550001195 Issued in CA
Legal business name
MCCLOUD HEALTHCARE CLINIC, INC.
Doing business as
Shasta Cascade Health Centers
Practice address
116 W Minnesota Ave
McCloud, CA 96057-1143
Phone
(530) 964-2389
Fax
(530) 964-3141
NPI assigned
Jun 22, 2005
Last updated
Mar 23, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2023

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

Authorized official

Name
Mr. Caleb J Ott
Title
Administrator
Phone
(530) 926-6309

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550001195 CA Primary
Rural Health Clinic/Center 261QR1300X 553934 CA

Addresses

Primary practice location

116 W Minnesota Ave
McCloud, CA 96057-1143

Mailing address

PO Box 1143
McCloud, CA 96057-1143
Phone (530) 964-2389

Other names 1

  • Shasta Cascade Health Centers Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031118001091 CA Part B Supplier - Clinic/Group Practice 3779494919 Receives reassigned benefits from 28 practitioners
2 other NPIs on this enrollment
Practice locations: Dunsmuir, CA; McCloud, CA; Mount Shasta, CA
O20100505000876 CA Part A Provider - Federally Qualified Health Center (FQHC) 3779494919 Practice locations: McCloud, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1164428488. Details of each certification follow.

Federally qualified health center certification: CCN 051168

Legal name
MCCLOUD HEALTHCARE CLINIC, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 23, 2009
Last certification
Dec 23, 2009
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 22, 1999 in CA
Enrollment address
116 W Minnesota Ave
McCloud, CA 96057-1143

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 2

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0981317McCloud Healthcare Clinic Inc116 W Minnesota Ave, McCloud, CA 96057Provider-performed microscopyMar 18, 2027

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

824 Pine St
Mount Shasta, CA 96067
Phone (530) 926-4528

828 Pine St
Mount Shasta, CA 96067
Phone (530) 926-4528

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Diane J Brickell Individual Corporate DirectorVice President Dec 23, 2009
James S Proffitt Individual Corporate OfficerInterim Ceo Jun 1, 2015
W-2 Managing EmployeeInterim Ceo May 29, 2014
Lucinda F Rinne Individual Corporate DirectorBoard Member Dec 31, 2012
Christine D Richey Individual Corporate DirectorBoard of Director Jan 1, 2009
Adrienne L Wieder Individual Corporate DirectorTreasurer Nov 1, 2004
Charlene C Fairchild Individual Corporate DirectorBoard Member Aug 16, 2011
Diane C Tolosano Individual Corporate DirectorBoard Member Jun 1, 1999
Milton L Shrader Individual Corporate DirectorBoard Member Feb 1, 2014
Anita K McFall Individual Corporate DirectorSecretary May 20, 2008

Practitioners & affiliated clinicians

Practitioners 30

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 30

NPI Registry JSON

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

{
    "created_epoch": "1119398400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1679529600000",
    "number": "1164428488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1143",
            "city": "MCCLOUD",
            "state": "CA",
            "postal_code": "960571143",
            "telephone_number": "530-964-2389",
            "fax_number": "530-964-3141"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "116 W MINNESOTA AVE",
            "city": "MCCLOUD",
            "state": "CA",
            "postal_code": "960571143",
            "telephone_number": "530-964-2389",
            "fax_number": "530-964-3141"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCCLOUD HEALTHCARE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-22",
        "last_updated": "2023-03-23",
        "certification_date": "2023-03-23",
        "status": "A",
        "authorized_official_last_name": "OTT",
        "authorized_official_first_name": "CALEB",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "530-926-6309",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "550001195",
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "CA",
            "license": "553934",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shasta Cascade Health Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in McCloud, CA

Sources for this page

Verify at the official NPI Registry.