Basic Information
| Provider Information | |||||||||
| NPI: | 1881873958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN DOOR COMMUNITY HEALTH CENTERS | ||||||||
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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: | 670 9TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 06/16/2017 | ||||||||
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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 | 207VX0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 05-1942 | 01 | CA | MEDICARE PART A | OTHER | FHC70779F | 05 | CA | MEDICAID | ZZZ75686Z | 01 | CA | MEDICARE PART B | OTHER | 05-1940 | 01 | CA | MEDICARE PART A | OTHER | 05-1941 | 01 | CA | MEDICARE PART A | OTHER | FHC03919F | 05 | CA | MEDICAID | FHC71103F | 05 | CA | MEDICAID | 55-1818 | 01 | CA | MEDICARE PART A | OTHER | FHC03890G | 05 | CA | MEDICAID | FHC03892F | 05 | CA | MEDICAID | ZZZ21581Z | 01 | CA | MEDICARE PART B | OTHER | ZZZ27933Z | 01 | CA | MEDICARE PART B | OTHER | FHC03920F | 05 | CA | MEDICAID | 05-1055 | 01 | CA | MEDICARE PART A | OTHER | 55-1916 | 01 | CA | MEDICARE PART A | OTHER | FHC70970F | 05 | CA | MEDICAID | 55-1917 | 01 | CA | MEDICARE PART A | OTHER | FHC70869F | 05 | CA | MEDICAID | ZZZ29825Z | 01 | CA | MEDICARE PART B | OTHER | ZZZ36797Z | 01 | CA | MEDICARE PART B | OTHER |