Provider Demographics
NPI:1669569109
Name:OPEN DOOR COMMUNITY HEALTH CENTERS
Entity type:Organization
Organization Name:OPEN DOOR COMMUNITY HEALTH CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHEYENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPETZLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-826-8633
Mailing Address - Street 1:670 NINTH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:2200 TYDD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1284
Practice Address - Country:US
Practice Address - Phone:707-441-1624
Practice Address - Fax:707-441-1253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000223261QF0400X
207VX0000X
CA110000223261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03920FMedicaid
CA05-1942Medicare ID - Type Unspecified
CAFHC03920FMedicaid