Healthcare Provider Details

I. General information

NPI: 1164665956
Provider Name (Legal Business Name): SOUTHERN COLORADO COMMUNITY ACTION AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 CANDELARIA DR
IGNACIO CO
81137-0800
US

IV. Provider business mailing address

PO BOX 800
IGNACIO CO
81137-0800
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-4517
  • Fax: 970-563-4504
Mailing address:
  • Phone: 970-563-4517
  • Fax: 970-563-4504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORI ANN NIEWOLD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 970-563-4517