Provider Demographics
NPI:1790778660
Name:COLUSA INDIAN COMMUNITY COUNCIL
Entity Type:Organization
Organization Name:COLUSA INDIAN COMMUNITY COUNCIL
Other - Org Name:COLUSA INDIAN COMMUNITY COUNCIL
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CATRINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-458-6542
Mailing Address - Street 1:3710 HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932
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
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:2005-08-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP53936FMedicaid
CA55-1948Medicare ID - Type Unspecified