Healthcare Provider Details

I. General information

NPI: 1053880245
Provider Name (Legal Business Name): COLUSA INDIAN COMMUNITY COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 5TH ST
COLUSA CA
95932-2467
US

IV. Provider business mailing address

3710 HIGHWAY 45
COLUSA CA
95932-4026
US

V. Phone/Fax

Practice location:
  • Phone: 530-458-3614
  • Fax: 530-458-4047
Mailing address:
  • Phone: 530-458-6542
  • Fax: 530-458-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CATRINA MARIE ROSS
Title or Position: DIRECTOR OF CLINIC OPERATIONS
Credential:
Phone: 530-458-6542