Basic Information
| Provider Information | |||||||||
| NPI: | 1306824891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONEJOS COUNTY GOVERNMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CONEJOS COUNTY EMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 215 | ||||||||
| Address2: | |||||||||
| City: | CONEJOS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811290215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192745804 | ||||||||
| FaxNumber: | 7192745850 | ||||||||
| Practice Location | |||||||||
| Address1: | 17705 US HIGHWAY 285 STE B | ||||||||
| Address2: | |||||||||
| City: | LA JARA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811400244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192745804 | ||||||||
| FaxNumber: | 7192745850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABEYTA | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7192745084 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 707458200 | 01 | DOL | OTHER | 06000194 | 05 | CO | MEDICAID |