Provider Demographics
NPI:1043840051
Name:COSTILLA COUNTY AMBULANCE DISTRICT
Entity Type:Organization
Organization Name:COSTILLA COUNTY AMBULANCE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VIGIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-580-2031
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:719-672-4271
Mailing Address - Fax:719-672-4277
Practice Address - Street 1:233 MAIN ST
Practice Address - Street 2:BUILDING 2
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152
Practice Address - Country:US
Practice Address - Phone:719-672-4271
Practice Address - Fax:270-744-8642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-17
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000168483Medicaid