LAKE COUNTY TRIBAL HEALTH SOUTHSHORE CLINIC
NPI 1063158038
Clinic/Center - Federally Qualified Health Center (FQHC) in Clearlake, CA
About Lake County Tribal Health Southshore Clinic NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
LAKE COUNTY TRIBAL HEALTH SOUTHSHORE CLINIC (NPI 1063158038) is a healthcare organization registered as a federally qualified health center (fqhc) in Clearlake, California and active in the NPI registry since May 2022. The organization holds a CLIA Microscopy certificate valid through December 16, 2026 and lists Ernesto Padilla, Ceo, as its authorized official.
NPPES Registry Identity
Specialties & Licenses
Medicare Participation & PECOS CMS
Medicare enrollment, revalidation and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
Lake County Tribal Health Southshore Clinic is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Medicare Revalidation Due Date
Revalidation due by March 31, 2027
Medicare-enrolled providers and suppliers confirm their enrollment information with CMS on a set cycle, every 5 years for most and every 3 years for medical equipment suppliers. CMS sets the due date for each enrollment.
Clinicians Billing Medicare Through This Organization
59Medicare enrollment records show 59 clinicians reassign Medicare billing to Lake County Tribal Health Southshore Clinic, which bills Medicare for the services they deliver. Of these, 1 practice at this address and 4 within 10 miles. Listed here are the 20 practicing nearest to this location.
Clinicians by Medicare Specialty 17
Nearest to this location (20)
See all 59Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
CLIA Laboratory Certificates CMS CLIA
Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.
Certificate for Provider-Performed Microscopy Procedures (PPMP) 05D0722889
Lake County Tribal Health · Lakeport, CAFrequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Lake County Tribal Health Southshore Clinic's NPI number?
The NPI number for Lake County Tribal Health Southshore Clinic is 1063158038. It was assigned to this organization in the NPPES registry on May 11, 2022.
Where is Lake County Tribal Health Southshore Clinic located?
Lake County Tribal Health Southshore Clinic is located at 14440 Olympic Drive, Clearlake, CA 95422. The listed phone number is (707) 263-8382.
What is Lake County Tribal Health Southshore Clinic's specialty?
The primary specialty registered for this NPI is Clinic/Center, specializing in Federally Qualified Health Center (FQHC), with taxonomy code 261QF0400X.
Is Lake County Tribal Health Southshore Clinic enrolled in Medicare?
Yes. Lake County Tribal Health Southshore Clinic is registered in the Medicare PECOS enrollment system.
When is Lake County Tribal Health Southshore Clinic's Medicare revalidation due?
According to the CMS Revalidation Due Date List (October 2026 release), the Medicare Non-DME Part B enrollment for this organization (California, Clinic/Group Practice) is due for revalidation by March 31, 2027. Medicare providers and suppliers revalidate their enrollment every 5 years, and medical equipment suppliers every 3 years. Confirm current requirements with your Medicare Administrative Contractor.
How many clinicians bill Medicare through Lake County Tribal Health Southshore Clinic?
According to the CMS Revalidation Reassignment List (October 2026 release), 59 clinicians in 17 Medicare specialties reassign their Medicare billing to Lake County Tribal Health Southshore Clinic. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. The largest specialties are Nurse Practitioner (11), Dentist (8) and Marriage and Family Therapist (7). Of these, 1 practice at this address and 4 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Does Lake County Tribal Health Southshore Clinic hold a CLIA laboratory certificate?
Yes. A Certificate for Provider-Performed Microscopy Procedures (PPMP) (number 05D0722889) is associated with this NPI, valid through December 16, 2026. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.
When was this NPI record last updated?
The NPPES record for Lake County Tribal Health Southshore Clinic was last updated on April 2, 2024. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 2 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Lake County Tribal Health Southshore Clinic · NPI 1063158038
Federally Qualified Health Center (FQHC) organization in Clearlake, California. Organization record, active in the CMS NPPES registry since May 11, 2022.
## Identity
- **NPI:** 1063158038 (Entity type: Organization)
- **Enumerated:** May 11, 2022
- **Primary specialty:** Clinic/Center - Federally Qualified Health Center (FQHC) · taxonomy 261QF0400X
- **Organization subpart:** Yes (part of Lake County Tribal Health Consortium Inc.)
- **Authorized official:** Ernesto Padilla, CEO
## Practice location
- **Address:** 14440 OLYMPIC DRIVE, Clearlake, CA 95422
- **Phone:** (707) 263-8382 · **Fax:** (707) 263-5019
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Medicare revalidation due:** March 31, 2027 (Non-DME Part B, California, Clinic/Group Practice) · CMS Revalidation Due Date List, October 2026 release
- **Clinicians billing through this organization:** 59 clinicians in 17 Medicare specialties reassign Medicare billing to this organization (form CMS-855R); largest: Nurse Practitioner (11), Dentist (8), Marriage and Family Therapist (7); 1 practice at this address and 4 within 10 miles; [full list](https://npiprofile.com/npi/1063158038/clinicians) · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** April 2, 2024
- **CLIA laboratory certificates:** 1 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1063158038) · Data from the CMS NPPES public registry.