Provider Demographics
NPI:1063861748
Name:MARILLAC CLINIC, INC.
Entity Type:Organization
Organization Name:MARILLAC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMACHANDRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-298-2235
Mailing Address - Street 1:2333 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2001
Mailing Address - Country:US
Mailing Address - Phone:970-298-1782
Mailing Address - Fax:970-298-1711
Practice Address - Street 1:3150 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506
Practice Address - Country:US
Practice Address - Phone:970-298-1782
Practice Address - Fax:970-298-1711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18U295261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15522865Medicaid
CO90252365Medicaid
CO27421767Medicaid
CO38402068Medicaid
CO72071362Medicaid
CO72071362Medicaid