Healthcare Provider Details

I. General information

NPI: 1922250976
Provider Name (Legal Business Name): COUNTY COMMISSIONERS OF BACA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 MAIN ST SUITE #4
SPRINGFIELD CO
81073-1548
US

IV. Provider business mailing address

741 MAIN ST SUITE #4
SPRINGFIELD CO
81073-1548
US

V. Phone/Fax

Practice location:
  • Phone: 719-523-6621
  • Fax: 719-523-6537
Mailing address:
  • Phone: 719-523-6621
  • Fax: 719-523-6537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number172848
License Number StateCO

VIII. Authorized Official

Name: MS. ROBIN TRUJILLO
Title or Position: AGENCY DIRECTOR
Credential: RN
Phone: 719-523-6621