Healthcare Provider Details

I. General information

NPI: 1528292521
Provider Name (Legal Business Name): JUDY M LANSING CACIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 MOUACHE DR.
IGNACIO CO
81137-0429
US

IV. Provider business mailing address

296 MOUACHE DR.
IGNACIO CO
81137-0429
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-4555
  • Fax: 970-563-4618
Mailing address:
  • Phone: 970-563-4555
  • Fax: 970-563-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number116600
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: