Basic Information
| Provider Information | |||||||||
| NPI: | 1346403375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUERFANO COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SPANISH PEAKS OUTREACH & WOMEN'S CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23500 US HIGHWAY 160 | ||||||||
| Address2: | |||||||||
| City: | WALSENBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810899524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197355144 | ||||||||
| FaxNumber: | 7197385138 | ||||||||
| Practice Location | |||||||||
| Address1: | 23450 US HIGHWAY 160 | ||||||||
| Address2: | |||||||||
| City: | WALSENBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810898100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197385200 | ||||||||
| FaxNumber: | 7195852521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | COLETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7197385137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0050X | Y | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
| ID | Type | State | Issuer | Description | 89770129 | 05 | CO | MEDICAID |