Basic Information
| Provider Information | |||||||||
| NPI: | 1679053946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SISKIYOU COMMUNITY HEALTH CENTER INC | ||||||||
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| OtherOrganizationName: | SBHC GRANTS PASS HIGH SCHOOL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 NW HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261051 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 830 NE 9TH ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414713455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOOTH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5414713455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SISKIYOU COMMUNITY HEALTH CENTER INC | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.