Provider Demographics
NPI:1124031190
Name:COUNTY COMMISSIONERS OF BACA
Entity Type:Organization
Organization Name:COUNTY COMMISSIONERS OF BACA
Other - Org Name:BACA COUNTY PUBLIC HEALTH AGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PUBLIC HEALTH
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNAE
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-523-6621
Mailing Address - Street 1:741 MAIN STREET
Mailing Address - Street 2:SUITE #4
Mailing Address - City:SPRINGFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81073
Mailing Address - Country:US
Mailing Address - Phone:719-523-6621
Mailing Address - Fax:719-523-6537
Practice Address - Street 1:741 MAIN STREET
Practice Address - Street 2:SUITE #4
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073
Practice Address - Country:US
Practice Address - Phone:719-523-6621
Practice Address - Fax:719-523-6537
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY COMMISSIONERS OF BAC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOTP164927AMedicaid
COCO04953Medicare UPIN
COCOTP164927AMedicaid