1295306132 NPI number — SANGRE DE CRISTO COMMUNITY CARE JONI FAIR HOSPICE HOUSE

Table of content: CARMEN ORTIZ CADC, CRM (NPI 1568283240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295306132 NPI number — SANGRE DE CRISTO COMMUNITY CARE JONI FAIR HOSPICE HOUSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANGRE DE CRISTO COMMUNITY CARE JONI FAIR HOSPICE HOUSE
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:
6
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:
1295306132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 PUEBLO BOULEVARD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81005-1595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-296-6205
Provider Business Mailing Address Fax Number:
719-545-4715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 PUEBLO BOULEVARD WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81005-1595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-296-6205
Provider Business Practice Location Address Fax Number:
719-545-4715
Provider Enumeration Date:
07/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
EGGING
Authorized Official First Name:
MELINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
719-542-0032

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40155030 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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