NPIMap

Organization Active NPI

McCloud Healthcare Clinic, Inc.

Doing business as Shasta Cascade Health Centers- Dunsmuir

  • Federally Qualified Health Center (FQHC)
  • Dunsmuir, CA
National Provider Identifier
1376893420
Registry record updated Nov 1, 2024
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- Dunsmuir
Practice address
4309 Stagecoach Road
Dunsmuir, CA 96025
Phone
(530) 235-4138
Fax
(530) 378-2453
NPI assigned
Sep 17, 2012
Last updated
Nov 1, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 1, 2024

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

Authorized official

Name
Mr. Caleb J Ott
Title
Ceo
Phone
(530) 964-2389

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550001195 CA Primary
Rural Health Clinic/Center 261QR1300X G32096 CA

Addresses

Primary practice location

4309 Stagecoach Road
Dunsmuir, CA 96025

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
00G320960MedicaidCA

Other names 1

  • Shasta Cascade Health Centers- Dunsmuir 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
This NPI is an additional NPI on the enrollment
Practice locations: Dunsmuir, CA; McCloud, CA; Mount Shasta, CA
O20130110000509 CA Part A Provider - Federally Qualified Health Center (FQHC) 3779494919 Practice locations: Dunsmuir, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376893420. Details of each certification follow.

Federally qualified health center certification: CCN 751007

Legal name
MCCLOUD HEALTHCARE CLINIC, INC.
Doing business as
DUNSMUIR COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 31, 2014
Last certification
Mar 31, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 22, 1999 in CA
Enrollment address
4309 Stagecoach Rd
Dunsmuir, CA 96025-1812

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.

National Provider Directory

National Provider Directory
Tax ID family
Urology Clinic5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
James S Proffitt Individual Corporate OfficerCeo Jun 1, 2015
W-2 Managing EmployeeCeo May 29, 2014 100%
Marlene Hines Individual Corporate DirectorVice President Dec 18, 2018
Christine D Richey Individual Corporate DirectorBoard Member Aug 1, 2008
Lynda S Hilliard Individual Corporate DirectorPresident Jun 18, 2019
Adrienne L Wieder Individual Corporate DirectorBoard Member Jun 1, 2002
Gilbert J Haas Individual Corporate DirectorTreasurer Mar 16, 2021
Charlene C Fairchild Individual Corporate DirectorBoard Member Jun 1, 2012
Diane C Tolosano Individual Corporate DirectorBoard Member Jun 1, 1999
Joni Van Wieren Individual Corporate DirectorBoard Member Mar 16, 2021
Milton L Shrader Individual Corporate DirectorBoard Member Feb 1, 2014
Anita K McFall Individual Corporate DirectorSecretary Apr 15, 2007

Practitioners & affiliated clinicians

Practitioners 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1347840000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730419200000",
    "number": "1376893420",
    "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": "4309 STAGECOACH ROAD",
            "city": "DUNSMUIR",
            "state": "CA",
            "postal_code": "96025",
            "telephone_number": "530-235-4138",
            "fax_number": "530-378-2453"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCCLOUD HEALTHCARE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-17",
        "last_updated": "2024-11-01",
        "certification_date": "2024-11-01",
        "status": "A",
        "authorized_official_last_name": "OTT",
        "authorized_official_first_name": "CALEB",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "530-964-2389",
        "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": "G32096",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00G320960",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shasta Cascade Health Centers- Dunsmuir",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dunsmuir, CA

Sources for this page

Verify at the official NPI Registry.