Basic Information
| Provider Information | |||||||||
| NPI: | 1447696877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CUSTER COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CUSTER COUNTY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 CITY WEST PKWY | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9526532525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 704 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | WESTCLIFFE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812528588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197832380 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2013 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | NIMNICHT | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7197832380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST CUSTER COUNTY HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.