Healthcare Provider Details

I. General information

NPI: 1629344908
Provider Name (Legal Business Name): SOUTHERN COLORADO UTE SERVICE UNIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 RUSTLING WILLOW ST
TOWAOC CO
81334-0049
US

IV. Provider business mailing address

PO BOX 49
TOWAOC CO
81334-0049
US

V. Phone/Fax

Practice location:
  • Phone: 970-565-4441
  • Fax: 970-565-9110
Mailing address:
  • Phone: 970-565-4441
  • Fax: 970-565-9110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierG7123
Identifier TypeMEDICAID
Identifier StateNM
Identifier Issuer
# 2
Identifier70000000009
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 3
Identifier05600002
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 4
Identifier708000
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name: MR. EARL DAVID WARD
Title or Position: HEALTH CENTER DIRECTOR
Credential:
Phone: 970-565-4441