1043840051 NPI number — COSTILLA COUNTY AMBULANCE DISTRICT

Table of content: BETH MATCHO PT (NPI 1093779472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043840051 NPI number — COSTILLA COUNTY AMBULANCE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSTILLA COUNTY AMBULANCE DISTRICT
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:
Provider Other Organization Name Type Code:
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:
1043840051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42002-9150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-672-4271
Provider Business Mailing Address Fax Number:
719-672-4277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 MAIN ST
Provider Second Line Business Practice Location Address:
BUILDING 2
Provider Business Practice Location Address City Name:
SAN LUIS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-672-4271
Provider Business Practice Location Address Fax Number:
270-744-8642
Provider Enumeration Date:
01/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
VIGIL
Authorized Official First Name:
SHERRI
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
719-580-2031

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000168483 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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