MEDICARE: COLUSA INDIAN COMMUNITY COUNCIL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1053880245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUSA INDIAN COMMUNITY COUNCIL

Provider Business Mailing Address
First Line	:	3710 HIGHWAY 45
Second Line	:
City	:	COLUSA
State	:	CA
Zip	:	95932-4026
Country	:	US
Telephone Number	:	530-458-6542
Fax Number	:	530-458-8660

Provider Business Practice Location Address
First Line	:	360 5TH ST
Second Line	:
City	:	COLUSA
State	:	CA
Zip	:	95932-2467
Country	:	US
Telephone Number	:	530-458-3614
Fax Number	:	530-458-4047

Authorized Official
Title or Position	:	DIRECTOR OF CLINIC OPERATIONS
Name	:	CATRINA MARIE ROSS
Credential	:
Telephone Number	:	530-458-6542

Provider Enumeration Date	:	11/16/2018
Last Update Date	:	11/16/2018

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