Healthcare Provider Details

I. General information

NPI: 1043349285
Provider Name (Legal Business Name): DOLORES SCHOOL DISTRICT RE-4A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 09/10/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N. 6TH STREET
DOLORES CO
81323
US

IV. Provider business mailing address

PO BOX 727
DOLORES CO
81323-0727
US

V. Phone/Fax

Practice location:
  • Phone: 970-882-7255
  • Fax:
Mailing address:
  • Phone: 970-882-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateCO

VIII. Authorized Official

Name: MARLEE HART
Title or Position: MEDICAID COORDINATOR
Credential:
Phone: 719-588-0397