Provider Demographics
NPI:1740428127
Name:SISKIYOU COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SISKIYOU COMMUNITY HEALTH CENTER, INC.
Other - Org Name:LORNA BYRNE MIDDLE SCHOOL SBHC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-471-3455
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1051
Mailing Address - Country:US
Mailing Address - Phone:541-471-3455
Mailing Address - Fax:541-471-9242
Practice Address - Street 1:101 S JUNCTION AVE
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9006
Practice Address - Country:US
Practice Address - Phone:541-592-6978
Practice Address - Fax:541-592-6702
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISKIYOU COMMUNITY HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-23
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR127725261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127725Medicaid
OR105575Medicare PIN