Basic Information
| Provider Information | |||||||||
| NPI: | 1295724797 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY-WIDE HEALTH SYSTEMS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA JARA DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | LA JARA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192748948 | ||||||||
| FaxNumber: | 7192748950 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | LA JARA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192748948 | ||||||||
| FaxNumber: | 7192748950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ARNOLDI | ||||||||
| AuthorizedOfficialFirstName: | JANIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7195895161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 280030 | 01 | CO | DELTA DENTAL | OTHER | 09721070 | 05 | CO | MEDICAID |