Basic Information
| Provider Information | |||||||||
| NPI: | 1205002136 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SISKIYOU COMMUNITY HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SISKIYOU COMMUNITY HEALTH CENTER DENTAL FACILITY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 NW HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796393 | ||||||||
| FaxNumber: | 5414712024 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 NW HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796393 | ||||||||
| FaxNumber: | 5414796489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOOTH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5414713455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 124Q00000X | H3448 | OR | N | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dental Hygienist | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.