Basic Information
| Provider Information | |||||||||
| NPI: | 1689206252 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPEN DOOR COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPEN DOOR GYNECOLOGY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 3770 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078257588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7078268633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OPEN DOOR COMMUNITY HEALTH CENTERS | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
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.