Basic Information
| Provider Information | |||||||||
| NPI: | 1841438231 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SISKIYOU COMMUNITY HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EVERGREEN ELEMENTARY SBHC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 NW HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414713455 | ||||||||
| FaxNumber: | 5414719242 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 W RIVER ST | ||||||||
| Address2: | |||||||||
| City: | CAVE JUNCTION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975239504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415926491 | ||||||||
| FaxNumber: | 5415926489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOOTH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5414713455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SISKIYOU COMMUNITY HEALTH CENTER INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 127725 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 127725 | 05 | OR | MEDICAID |