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	261QF0400X	Federally Qualified Health Center (FQHC)		CA

General Provider Information

NPI Number	:	1790778660
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
Country	:	US
Telephone Number	:	530-458-5501
Fax Number	:	530-458-8660

Provider Business Practice Location Address
First Line	:	3710 HIGHWAY 45
Second Line	:
City	:	COLUSA
State	:	CA
Zip	:	95932
Country	:	US
Telephone Number	:	530-458-5501
Fax Number	:	530-458-8660

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

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	06/16/2018

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