NPIMap

Organization Active NPI

McCloud Healthcare Clinic, Inc.

  • Dentist
  • Dunsmuir, CA
National Provider Identifier
1457059768
Registry record updated Feb 16, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
MCCLOUD HEALTHCARE CLINIC, INC.
Practice address
4303 Stagecoach Rd
Dunsmuir, CA 96025-1812
Phone
(530) 926-6309
NPI assigned
Feb 16, 2023
Last updated
Feb 16, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 16, 2023

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

Authorized official

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X Primary
Dental HygienistGroup: 193200000X MULTI-SPECIALTY GROUP 124Q00000X

Addresses

Primary practice location

4303 Stagecoach Rd
Dunsmuir, CA 96025-1812

Mailing address

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20231206004049 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 1457059768. Details of each certification follow.

Federally qualified health center certification: CCN A01811

Legal name
MCCLOUD HEALTHCARE CLINIC, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 21, 2023
Last certification
Aug 21, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 22, 1999 in CA
Enrollment address
4303 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).

National Provider Directory

National Provider Directory
Tax ID family
Robert M Adams MD5 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.

Locations

4303 Stagecoach Rd
Dunsmuir, CA 96025
Phone (530) 235-4157

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
Barry Stacy Individual Corporate DirectorBoard Member May 16, 2023
Caleb Ott Individual Corporate DirectorCeo Dec 28, 2022
W-2 Managing EmployeeCeo Jan 1, 2014
Marlene Hines Individual Corporate DirectorVice President Dec 18, 2018
Lynda S Hilliard Individual Corporate DirectorPresident Jun 18, 2019
Charlene C Fairchild Individual Corporate DirectorBoard Member Apr 1, 2010
Robert Hilliard Individual Corporate DirectorBoard Member Oct 18, 2022
Karen Kennedy Individual Corporate DirectorBoard Member Mar 21, 2023
Milton L Shrader Individual Corporate DirectorTreasurer Feb 1, 2014
Michael Quinn Individual Corporate DirectorBoard Member Mar 21, 2023
Anita K McFall Individual Corporate OfficerCommunity Member May 1, 2022
Jennifer Roberts Individual Corporate DirectorBoard Member Dec 20, 2022

Practitioners & affiliated clinicians

Practitioners 20

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 20

NPI Registry JSON

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

{
    "created_epoch": "1676505600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1676505600000",
    "number": "1457059768",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4303 STAGECOACH RD",
            "city": "DUNSMUIR",
            "state": "CA",
            "postal_code": "960251812",
            "telephone_number": "530-926-6309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCCLOUD HEALTHCARE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-02-16",
        "last_updated": "2023-02-16",
        "certification_date": "2023-02-16",
        "status": "A",
        "authorized_official_last_name": "OTT",
        "authorized_official_first_name": "CALEB",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "530-926-6309",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Dunsmuir, CA

Sources for this page

Verify at the official NPI Registry.