Healthcare Provider Details

I. General information

NPI: 1366709263
Provider Name (Legal Business Name): DOLORES MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 CENTRAL AVENUE
DOLORES CO
81323
US

IV. Provider business mailing address

P.O BOX 908
DOLORES CO
81323
US

V. Phone/Fax

Practice location:
  • Phone: 970-882-7221
  • Fax:
Mailing address:
  • Phone: 970-882-7221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberNP 990365
License Number StateCO

VIII. Authorized Official

Name: ALLAN BURNSIDE
Title or Position: MD
Credential: MD
Phone: 970-882-7221