Healthcare Provider Details

I. General information

NPI: 1992704761
Provider Name (Legal Business Name): WEST CUSTER COUNTY HOSPITAL DIST.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 EDWARDS ST
WESTCLIFFE CO
81252-8588
US

IV. Provider business mailing address

PO BOX 120
WESTCLIFFE CO
81252-0120
US

V. Phone/Fax

Practice location:
  • Phone: 719-783-2380
  • Fax:
Mailing address:
  • Phone: 719-783-2380
  • Fax: 719-783-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCO

VIII. Authorized Official

Name: MRS. TOLOA PEARL
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 719-783-2380