1629344908 NPI number — SOUTHERN COLORADO UTE SERVICE UNIT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629344908 NPI number — SOUTHERN COLORADO UTE SERVICE UNIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN COLORADO UTE SERVICE UNIT
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:
WHITE MESA HEALTH STATION
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:
1629344908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 49
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWAOC
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81334-0049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-565-4441
Provider Business Mailing Address Fax Number:
970-565-9110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
232 RUSTLING WILLOW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWAOC
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81334-0049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-565-4441
Provider Business Practice Location Address Fax Number:
970-565-9110
Provider Enumeration Date:
03/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WARD
Authorized Official First Name:
EARL
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
HEALTH CENTER DIRECTOR
Authorized Official Telephone Number:
970-565-4441

Provider Taxonomy Codes

  • Taxonomy code: 261QP0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G7123 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 70000000009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05600002 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 708000 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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