Basic Information
| Provider Information | |||||||||
| NPI: | 1598858169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN DOOR COMMUNITY HEALTH CENTERS | ||||||||
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| OtherOrganizationName: | MCKINLEYVILLE COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 1644 CENTRAL AVENUE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MCKINLEYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078393068 | ||||||||
| FaxNumber: | 7078393827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | SPETZLER | ||||||||
| AuthorizedOfficialFirstName: | CHEYENNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7078268633 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 010000340 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC70779F | 05 | CA | MEDICAID |