1093163800 NPI number — MARILLAC CLINIC, INC.

Table of content: (NPI 1093163800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093163800 NPI number — MARILLAC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARILLAC CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093163800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2333 N 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81501-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-298-1782
Provider Business Mailing Address Fax Number:
970-298-1711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 PITKIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-200-1600
Provider Business Practice Location Address Fax Number:
970-200-1611
Provider Enumeration Date:
06/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RAMACHANDRAN
Authorized Official First Name:
LATA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
970-200-1600

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  18U295 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 90252365 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38402068 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 72071362 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15522865 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27421767 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com