Basic Information
| Provider Information | |||||||||
| NPI: | 1568937639 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOLORES COUNTY HEALTH ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 576 | ||||||||
| Address2: | |||||||||
| City: | DOVE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813240576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706773628 | ||||||||
| FaxNumber: | 9706772540 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | CORTEZ | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813213562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705651800 | ||||||||
| FaxNumber: | 9705651801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2018 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | PEHRSON | ||||||||
| AuthorizedOfficialFirstName: | LINCOLN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9706773628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DOLORES COUNTY HEALTH ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 05682000 | 05 | CO | MEDICAID |