Basic Information
| Provider Information | |||||||||
| NPI: | 1710954433 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOLORES COUNTY HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 576 | ||||||||
| Address2: | |||||||||
| City: | DOVE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813240576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706772291 | ||||||||
| FaxNumber: | 9706772540 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | DOVE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813240576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706772291 | ||||||||
| FaxNumber: | 9706772540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 05/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DIANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9706772291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 0589 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 05682000 | 05 | CO | MEDICAID |