Provider Demographics
NPI:1114918000
Name:MONTEZUMA COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:MONTEZUMA COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-565-3056
Mailing Address - Street 1:106 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3119
Mailing Address - Country:US
Mailing Address - Phone:970-565-3056
Mailing Address - Fax:970-565-0647
Practice Address - Street 1:106 W NORTH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3119
Practice Address - Country:US
Practice Address - Phone:970-565-3056
Practice Address - Fax:970-565-0647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9802662251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04423091Medicaid
CO34888047Medicaid
CO34888047Medicaid