Basic Information
| Provider Information | |||||||||
| NPI: | 1104275882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARILLAC CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702981782 | ||||||||
| FaxNumber: | 9702981711 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 29 1/2 RD | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702981782 | ||||||||
| FaxNumber: | 9702981711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAMACHANDRAN | ||||||||
| AuthorizedOfficialFirstName: | LATA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9702982235 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| 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 | 15522865 | 05 | CO | MEDICAID | 27421767 | 05 | CO | MEDICAID | 72071362 | 05 | CO | MEDICAID | 90252365 | 05 | CO | MEDICAID | 38402068 | 05 | CO | MEDICAID |