Provider Demographics
NPI:1144582925
Name:COLUSA INDIAN HEALTH CLINIC
Entity Type:Organization
Organization Name:COLUSA INDIAN HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-458-5501
Mailing Address - Street 1:3710 HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-4026
Mailing Address - Country:US
Mailing Address - Phone:530-458-5501
Mailing Address - Fax:530-458-8660
Practice Address - Street 1:3710 HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-4026
Practice Address - Country:US
Practice Address - Phone:530-458-5501
Practice Address - Fax:530-458-8660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUSA INDIAN COMMUNITY COUNCIL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA021859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty