Provider Demographics
NPI:1083764443
Name:SAN JUAN BASIN PUBLIC HEALTH
Entity Type:Organization
Organization Name:SAN JUAN BASIN PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-247-5702
Mailing Address - Street 1:281 SAWYER DR
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-3409
Mailing Address - Country:US
Mailing Address - Phone:970-247-5702
Mailing Address - Fax:970-247-9126
Practice Address - Street 1:281 SAWYER DR
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-3409
Practice Address - Country:US
Practice Address - Phone:970-247-5702
Practice Address - Fax:970-247-9126
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN BASIN PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04002150Medicaid