| Marillac Clinic, Inc | |
|
510 29 1/2 Rd Grand Junction CO 81504 | |
| (970) 298-1782 | |
| (970) 298-1711 |
| Full Name | Marillac Clinic, Inc |
|---|---|
| Speciality | Clinic/Center |
| Location | 510 29 1/2 Rd, Grand Junction, Colorado |
| Authorized Official Name and Position | Lata Ramachandran (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 9702982235 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Marillac Clinic, Inc 2333 N 6th St Grand Junction CO 81501-2001 Ph: (970) 298-1782 | Marillac Clinic, Inc 510 29 1/2 Rd Grand Junction CO 81504 Ph: (970) 298-1782 |
| NPI Number | 1104275882 |
|---|---|
| Provider Enumeration Date | 06/03/2016 |
| Last Update Date | 09/21/2020 |
| Medicare PECOS PAC ID | 1052634748 |
|---|---|
| Medicare Enrollment ID | O20190617000583 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104275882 | NPI | - | NPPES |
| 15522865 | Medicaid | CO | |
| 27421767 | Medicaid | CO | |
| 72071362 | Medicaid | CO | |
| 90252365 | Medicaid | CO | |
| 38402068 | Medicaid | CO |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | 18U295 (Colorado) | Primary |
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