NPIMap

McCloud Healthcare Clinic, Inc.

Organization Active NPI Federally Qualified Health Center (FQHC) · McCloud, CA

NPI 1164428488 · NPPES record last updated Mar 23, 2023

Key facts

NPI
1164428488
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
License
550001195 (CA)
Legal business name
MCCLOUD HEALTHCARE CLINIC, INC.
Practice address
116 W Minnesota Ave
McCloud, CA 96057-1143
Phone
(530) 964-2389
Fax
(530) 964-3141
NPI assigned
Jun 22, 2005
Organization subpart
No

Authorized official

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

Other NPIs on the same Medicare enrollment 2

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

Other NPIs with the same Medicare PAC ID 3

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

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 30

Laboratory certificates & supplier records

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

CLIA laboratory certificates

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

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in CA

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
Corporation · Non-profit
Incorporated
Jan 22, 1999 in CA
Enrollment address
116 W Minnesota Ave
McCloud, CA 96057-1143

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 Director
Vice President		 Dec 23, 2009
James S Proffitt
Individual 		Corporate Officer
Interim Ceo		 Jun 1, 2015
W-2 Managing Employee
Interim Ceo		 May 29, 2014
Lucinda F Rinne
Individual 		Corporate Director
Board Member		 Dec 31, 2012
Christine D Richey
Individual 		Corporate Director
Board of Director		 Jan 1, 2009
Adrienne L Wieder
Individual 		Corporate Director
Treasurer		 Nov 1, 2004
Charlene C Fairchild
Individual 		Corporate Director
Board Member		 Aug 16, 2011
Diane C Tolosano
Individual 		Corporate Director
Board Member		 Jun 1, 1999
Milton L Shrader
Individual 		Corporate Director
Board Member		 Feb 1, 2014
Anita K McFall
Individual 		Corporate Director
Secretary		 May 20, 2008

Medicare enrollment records

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

National Provider Directory

Locations

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

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550001195 CA Yes
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 identifiers

IdentifierTypeStateIssuer
ZZZ24754ZOtherCAMEDICARE PART B
RHM53934FMedicaidCA
ZZZ24754ZOtherCABCBS
55-3934OtherCACAHABA GBA

Other names

  • Shasta Cascade Health Centers Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Mar 23, 2023.

{
    "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": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B",
            "identifier": "ZZZ24754Z",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RHM53934F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "ZZZ24754Z",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAHABA GBA",
            "identifier": "55-3934",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shasta Cascade Health Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in McCloud, CA

All providers in McCloud, CA · Federally Qualified Health Center (FQHC) in California

Sources for this page

Verify at the official NPI Registry.