Basic Information
Provider Information
NPI: 1497840656
EntityType: 2
ReplacementNPI:  
OrganizationName: OPEN DOOR COMMUNITY HEALTH CENTERS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: DEL NORTE COMMUNITY HEALTH CENTER
OtherOrganizationType: 3
OtherLastName:  
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OtherCredential:  
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Mailing Information
Address1: 670 NINTH STREET
Address2: SUITE 203
City: ARCATA
State: CA
PostalCode: 95521
CountryCode: US
TelephoneNumber: 7078268633
FaxNumber: 7078268638
Practice Location
Address1: 550 E WASHINGTON BLVD
Address2:  
City: CRESCENT CITY
State: CA
PostalCode: 955318342
CountryCode: US
TelephoneNumber: 7074656925
FaxNumber: 7074656070
Other Information
ProviderEnumerationDate: 10/04/2006
LastUpdateDate: 06/16/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SPETZLER
AuthorizedOfficialFirstName: CHEYENNE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: COO
AuthorizedOfficialTelephone: 7078268633
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207VX0000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
261QF0400X010000215CAY Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
FHC03919F05CA MEDICAID


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