Organization
MARILLAC CLINIC, INC.
Active
Other names
PrimeHealthplus
Organization subpart
No
Provider details
NPI number
Authorized official
LATA RAMACHANDRAN (EXECUTIVE DIRECTOR)
(970) 200-1600
Entity
Organization
Contact information
Practice address
302 PITKIN AVE, GRAND JUNCTION, CO 81501
(970) 200-1600
(970) 200-1611
Mailing address
2333 N 6TH ST, GRAND JUNCTION, CO 81501-2001
(970) 298-1782
(970) 298-1711
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
18U295
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
15522865
—
CO
05
—
27421767
—
CO
05
—
38402068
—
CO
05
—
72071362
—
CO
05
—
90252365
—
CO
Enumeration date
06/02/2016
Last updated
08/05/2025
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