Basic Information
| Provider Information | |||||||||
| NPI: | 1801530928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARILLAC CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 N 6TH ST | ||||||||
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| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2139 N 12TH ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702001600 | ||||||||
| FaxNumber: | 9706928301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2022 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | RAMACHANDRAN | ||||||||
| AuthorizedOfficialFirstName: | LATA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9702001600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/10/2022 | ||||||||
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.