Provider Demographics
NPI:1134569650
Name:PRIME HEALTHCARE SERVICES - SHASTA LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES - SHASTA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING ASSOCIATE GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-259-4706
Mailing Address - Street 1:1100 BUTTE ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0852
Mailing Address - Country:US
Mailing Address - Phone:530-244-5454
Mailing Address - Fax:
Practice Address - Street 1:1100 BUTTE ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0852
Practice Address - Country:US
Practice Address - Phone:530-244-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000023273R00000X
CA273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0177738Medicaid
CA05S764Medicare Oscar/Certification
CA05S764Medicare PIN