Healthcare Provider Details

I. General information

NPI: 1053956268
Provider Name (Legal Business Name): LA JUNTA HEALTH SERVICE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 12/12/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DARLENE DRIVE
LA JUNTA CO
81050
US

IV. Provider business mailing address

1 DARLENE DRIVE
LA JUNTA CO
81050
US

V. Phone/Fax

Practice location:
  • Phone: 719-363-1700
  • Fax: 303-987-0434
Mailing address:
  • Phone: 719-363-1700
  • Fax: 303-987-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier9000238087
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MARY KORETKE
Title or Position: DIRECTOR, COST REPORTING
Credential:
Phone: 720-974-6278