1013917921 NPI number — COUNTY OF FREMONT

Table of content: (NPI 1013917921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013917921 NPI number — COUNTY OF FREMONT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF FREMONT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FREMONT COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013917921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 N 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANON CITY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81212-3303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-276-7450
Provider Business Mailing Address Fax Number:
719-276-7451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 N 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANON CITY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81212-3303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-276-7450
Provider Business Practice Location Address Fax Number:
719-276-7451
Provider Enumeration Date:
07/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MIKLICH
Authorized Official First Name:
RICK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
719-276-7449

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04446092 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: COB5228 . This is a "MEDICARE 73 MASS IMMUNIZATION ROSTER BILLER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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