Basic Information
Provider Information | |||||||||
NPI: | 1255470225 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLEAR CREEK COUNTY NURSING SERVICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3669 | ||||||||
Address2: |   | ||||||||
City: | IDAHO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 804523669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3035673147 | ||||||||
FaxNumber: | 3035673132 | ||||||||
Practice Location | |||||||||
Address1: | 1531 COLORADO BLVD. | ||||||||
Address2: |   | ||||||||
City: | IDAHO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 804523669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3035673147 | ||||||||
FaxNumber: | 3035673132 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARTA | ||||||||
AuthorizedOfficialFirstName: | JEAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | NURSING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 3035673147 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 38280 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
ID | Type | State | Issuer | Description | 04540209 | 05 | CO |   | MEDICAID | 07382807 | 05 | CO |   | MEDICAID |