Basic Information
Provider Information | |||||||||
NPI: | 1093163800 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARILLAC CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2333 N 6TH ST | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815012001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702981782 | ||||||||
FaxNumber: | 9702981711 | ||||||||
Practice Location | |||||||||
Address1: | 302 PITKIN AVE | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 81501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702981782 | ||||||||
FaxNumber: | 9702981711 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2016 | ||||||||
LastUpdateDate: | 09/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAMACHANDRAN | ||||||||
AuthorizedOfficialFirstName: | LATA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9702982235 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | 18U295 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 90252365 | 05 | CO |   | MEDICAID | 15522865 | 05 | CO |   | MEDICAID | 27421767 | 05 | CO |   | MEDICAID | 72071362 | 05 | CO |   | MEDICAID | 38402068 | 05 | CO |   | MEDICAID |