Basic Information
| Provider Information | |||||||||
| NPI: | 1386675619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON COUNTY COLORADO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WASHINGTON COUNTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 482 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807201149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703452262 | ||||||||
| FaxNumber: | 9703452265 | ||||||||
| Practice Location | |||||||||
| Address1: | 482 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807201149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703452262 | ||||||||
| FaxNumber: | 9703452265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 06/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FILLA | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9703452701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.