Healthcare Provider Details

I. General information

NPI: 1023215472
Provider Name (Legal Business Name): OTERO COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 WEST THIRD ST. ROOM 111
LA JUNTA CO
81050-1691
US

IV. Provider business mailing address

13 WEST THIRD ST. ROOM 111
LA JUNTA CO
81050-1691
US

V. Phone/Fax

Practice location:
  • Phone: 719-383-3040
  • Fax: 719-383-3060
Mailing address:
  • Phone: 719-383-3040
  • Fax: 719-383-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number04413092
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier07396187
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier07321771
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 3
Identifier07452618
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MRS. LORENE NELSON
Title or Position: NURSING SUPERVISOR
Credential: RN
Phone: 719-383-3040