Basic Information
| Provider Information | |||||||||
| NPI: | 1902471295 | ||||||||
| 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 | ||||||||
| TelephoneNumber: | 9702001600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 562 29 RD | ||||||||
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| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815048901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702001600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2021 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | RAMACHANDRAN | ||||||||
| AuthorizedOfficialFirstName: | LATA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9702001629 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
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.