Provider Demographics
NPI:1518239219
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:MS
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:970-298-2235
Mailing Address - Fax:970-298-1711
Practice Address - Street 1:2333 N 6TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-298-1782
Practice Address - Fax:970-298-6314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 207Q00000X, 363A00000X, 363L00000X
CO18U295261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38402068Medicaid
CO72071362Medicaid
CO15522865Medicaid
CO27421767Medicaid
CO90252365Medicaid
CO39400247Medicaid
CO383321Medicare PIN