Active NPI
Northeastern Rural Health Clinics
- Family Medicine Physician
- Susanville, CA
National Provider Identifier
1477563518
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- 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
- Organization subpart
- Yes
- Parent organization
- NORTHEASTERN HEALTH CENTER
NPPES NPI Registry
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) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 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
Other identifiers 6
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 080061921 | Other | RRMCR MORGAN | |
| FHC70081F | Medicaid | CA | |
| 080005169 | Other | RRMCR DOZIER | |
| 080119610 | Other | RRMCR DAVAINIS | |
| 080042465 | Other | RRMCR HOLMES | |
| ZZZ87615Z | Other | BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
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
- Corporation
- Incorporated
- Nov 15, 1977 in CA
- Enrollment address
- 1850 Spring Ridge Dr
Susanville, CA 96130-6100 - Related CCNs
- 051805
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.
| Name | Role | Since | Share |
|---|---|---|---|
| Eula Johnson | Corporate Director | Dec 7, 2005 | |
| Ronda Gillis | Corporate Director | Apr 17, 2024 | |
| Maudy Kresge | W-2 Managing Employee | Jun 15, 2020 | |
| Marjorie Garrod | Corporate Director | May 7, 2014 | |
| Craig Herron | Corporate Director | Jul 19, 2023 | |
| Lauren Rojas | Corporate Director | Aug 20, 2023 | |
| Mark Solomon | Corporate Director | May 17, 2023 | |
| Garrett Taylor | Corporate Officer | Sep 8, 2025 | |
| Carol Curry | Corporate Director | Nov 12, 2019 | |
| Lacey Lively | Corporate Officer | Sep 3, 2025 |
National Provider Directory
National Provider Directory- Part of
- Northeastern Rural Health Clinics
Other NPIs on the same Medicare enrollment 1
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
-
- Family Medicine Physician
- Westwood, CA
- NPI 1336150051
O20050630001203
Other NPIs with the same Medicare PAC ID 1
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
Practitioners 38
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Family Medicine Physician
- Susanville, CA
- NPI 1437156866
CA, Family Medicine
-
- Family Medicine Physician
- Woodburn, OR
- NPI 1366837163
CA, Family Medicine
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0618660 | Northeastern Rural Health Clinics | Certificate of waiver | May 11, 2027 |
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": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RRMCR MORGAN",
"identifier": "080061921",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "FHC70081F",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RRMCR DOZIER",
"identifier": "080005169",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RRMCR DAVAINIS",
"identifier": "080119610",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RRMCR HOLMES",
"identifier": "080042465",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE SHIELD",
"identifier": "ZZZ87615Z",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Susanville, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 10, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.