NPIMap

Organization Active NPI

Northeastern Rural Health Clinics

  • Family Medicine Physician
  • Susanville, CA
National Provider Identifier
1477563518
Registry record updated Sep 10, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
NORTHEASTERN RURAL HEALTH CLINICS
Practice address
1850 Spring Ridge Dr
Susanville, CA 96130-6100
Phone
(530) 251-5000
Fax
(530) 252-1340
NPI assigned
Aug 9, 2006
Last updated
Sep 10, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTHEASTERN HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 10, 2025

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

Authorized official

Name
Lacey L Lively
Title
Ceo
Phone
(530) 251-5000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

1850 Spring Ridge Dr
Susanville, CA 96130-6100

Mailing address

1850 Spring Ridge Dr
Susanville, CA 96130-6100
Phone (530) 251-5000

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041216000472 CA Part A Provider - Federally Qualified Health Center (FQHC) 0446225254 Practice locations: Susanville, CA
O20050630001203 CA Part B Supplier - Clinic/Group Practice 0446225254 Receives reassigned benefits from 36 practitioners
1 other NPI on this enrollment
Practice locations: Susanville, CA; Westwood, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477563518. Details of each certification follow.

Federally qualified health center certification: CCN 051008

Legal name
NORTHEASTERN RURAL HEALTH CLINICS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 16, 2005
Last certification
May 16, 2005
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 15, 1977 in CA
Enrollment address
1850 Spring Ridge Dr
Susanville, CA 96130-6100
Related CCNs
051805

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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
05D0618660Northeastern Rural Health Clinics1850 Spring Ridge Dr, Susanville, CA 96130Certificate of waiverMay 11, 2027

National Provider Directory

National Provider Directory
Part of
Westwood Family Practic

Locations

1306 Riverside Dr
Susanville, CA 96130
Phone (530) 257-5335

1850 Spring Ridge Dr
Susanville, CA 96130
Phone (530) 251-5000

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Eula Johnson Individual Corporate DirectorBoard Member Dec 7, 2005
Ronda Gillis Individual Corporate Director Apr 17, 2024
Maudy Kresge Individual W-2 Managing EmployeeRevenue Cycle Manager Jun 15, 2020
Marjorie Garrod Individual Corporate DirectorBoard Member May 7, 2014
Craig Herron Individual Corporate DirectorBoard Member Jul 19, 2023
Lauren Rojas Individual Corporate DirectorBoard Member Aug 20, 2023
Mark Solomon Individual Corporate DirectorBoard Member May 17, 2023
Garrett Taylor Individual Corporate OfficerCfo Sep 8, 2025
Carol Curry Individual Corporate DirectorBoard Member Nov 12, 2019
Lacey Lively Individual Corporate OfficerCeo Sep 3, 2025

Practitioners & affiliated clinicians

Practitioners 37

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 37

NPI Registry JSON

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

{
    "created_epoch": "1155081600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757462400000",
    "number": "1477563518",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1850 SPRING RIDGE DR",
            "city": "SUSANVILLE",
            "state": "CA",
            "postal_code": "961306100",
            "telephone_number": "530-251-5000",
            "fax_number": "530-252-1340"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1850 SPRING RIDGE DR",
            "city": "SUSANVILLE",
            "state": "CA",
            "postal_code": "961306100",
            "telephone_number": "530-251-5000",
            "fax_number": "530-252-1340"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEASTERN RURAL HEALTH CLINICS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTHEASTERN HEALTH CENTER",
        "enumeration_date": "2006-08-09",
        "last_updated": "2025-09-10",
        "certification_date": "2025-09-10",
        "status": "A",
        "authorized_official_last_name": "LIVELY",
        "authorized_official_first_name": "LACEY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "530-251-5000"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Susanville, CA

Sources for this page

Verify at the official NPI Registry.