Basic Information
| Provider Information | |||||||||
| NPI: | 1235174392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAGOSA SPRINGS FAMILY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7638 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370638 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 S PAGOSA BLVD | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811477910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004620975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ASH | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE CONTACT | ||||||||
| AuthorizedOfficialTelephone: | 9707314131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 60502711 | 05 | CO | MEDICAID |