Basic Information
| Provider Information | |||||||||
| NPI: | 1003955758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LASSEN MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305270141 | ||||||||
| FaxNumber: | 5305273720 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305270141 | ||||||||
| FaxNumber: | 5305273720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | FISCHER | ||||||||
| AuthorizedOfficialFirstName: | AGNES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 5305284477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHM53955F | 05 | CA | MEDICAID | LAB18474G | 05 | CA | MEDICAID | GR0089250 | 05 | CA | MEDICAID | LAB18474F | 05 | CA | MEDICAID |