Basic Information
| Provider Information | |||||||||
| NPI: | 1992704761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CUSTER COUNTY HOSPITAL DIST. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CUSTER COUNTY HCBS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 120 | ||||||||
| Address2: | |||||||||
| City: | WESTCLIFFE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812520120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197832380 | ||||||||
| FaxNumber: | 7197832377 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | WESTCLIFFE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812528588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197832380 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PEARL | ||||||||
| AuthorizedOfficialFirstName: | TOLOA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7197832380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04141362 | 05 | CO | MEDICAID |