Basic Information
| Provider Information | |||||||||
| NPI: | 1629608427 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST TELLER COUNTY EMERGENCY MEDICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 826 | ||||||||
| Address2: | |||||||||
| City: | CRIPPLE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808130826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194944836 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 EAST BENNETT AVENUE | ||||||||
| Address2: | |||||||||
| City: | CRIPPLE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194944836 | ||||||||
| FaxNumber: | 2707448642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2020 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHOEMAKER | ||||||||
| AuthorizedOfficialFirstName: | CANDACE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7196890240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 90000158052 | 05 | CO | MEDICAID |