Basic Information
Provider Information | |||||||||
NPI: | 1124475629 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SALIDA HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEART OF THE ROCKIES REGIONAL DIALYSIS CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 429 | ||||||||
Address2: |   | ||||||||
City: | SALIDA | ||||||||
State: | CO | ||||||||
PostalCode: | 812010429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195302200 | ||||||||
FaxNumber: | 7195302232 | ||||||||
Practice Location | |||||||||
Address1: | 1000 RUSH DR | ||||||||
Address2: |   | ||||||||
City: | SALIDA | ||||||||
State: | CO | ||||||||
PostalCode: | 812019627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195302200 | ||||||||
FaxNumber: | 7195302232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2016 | ||||||||
LastUpdateDate: | 05/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FAGERBERG | ||||||||
AuthorizedOfficialFirstName: | LESLEY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7195302213 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.