1306252051 NPI number — OPEN DOOR COMMUNITY HEALTH CENTERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306252051 NPI number — OPEN DOOR COMMUNITY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN DOOR COMMUNITY HEALTH CENTERS
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:
FORTUNA COMMUNITY HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1306252051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCATA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95521-5770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-826-8633
Provider Business Mailing Address Fax Number:
707-826-8638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3750 ROHNERVILLE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORTUNA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-725-6101
Provider Business Practice Location Address Fax Number:
707-725-2978
Provider Enumeration Date:
07/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
STARR
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
707-826-8633

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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