Provider Demographics
NPI:1427046903
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:ACTING CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MHA
Authorized Official - Phone:541-472-4777
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:541-472-4777
Mailing Address - Fax:541-471-1439
Practice Address - Street 1:1701 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1257
Practice Address - Country:US
Practice Address - Phone:541-471-3455
Practice Address - Fax:541-471-1439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2024-09-18
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
ORP54367Medicare UPIN
ORP03004Medicare UPIN
ORD36236Medicare UPIN
ORP03003Medicare UPIN
ORR63504Medicare UPIN
OR127725Medicaid
ORH00453Medicare UPIN
ORE31838Medicare UPIN
ORA06131Medicare UPIN
ORG86956Medicare UPIN
ORI68997Medicare UPIN
ORP03006Medicare UPIN
ORP03003Medicare UPIN
OR381865Medicare ID - Type UnspecifiedCJ