Basic Information
Provider Information | |||||||||
NPI: | 1477183408 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONEJOS COUNTY GOVERNMENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CONEJOS COUNTY EMS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 215 | ||||||||
Address2: |   | ||||||||
City: | CONEJOS | ||||||||
State: | CO | ||||||||
PostalCode: | 811290215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7192745804 | ||||||||
FaxNumber: | 2707448642 | ||||||||
Practice Location | |||||||||
Address1: | 17705 STATE HWY 285 | ||||||||
Address2: | SUITE B | ||||||||
City: | LA JARA | ||||||||
State: | CO | ||||||||
PostalCode: | 81140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7192745804 | ||||||||
FaxNumber: | 2707448642 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2020 | ||||||||
LastUpdateDate: | 01/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABEYTA | ||||||||
AuthorizedOfficialFirstName: | ERNEST | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7192745084 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   |   | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 9000157470 | 05 | CO |   | MEDICAID |