Provider Demographics
NPI:1306500574
Name:SISKIYOU COMMUNITY HEALTH CENTER INC
Entity type:Organization
Organization Name:SISKIYOU COMMUNITY HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
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 1:6741 MONUMENT DR
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-8536
Practice Address - Country:US
Practice Address - Phone:541-479-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISKIYOU COMMUNITY HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)