Provider Demographics
NPI:1134139504
Name:COUNTY OF KIOWA HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:COUNTY OF KIOWA HOSPITAL DISTRICT
Other - Org Name:WILEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-438-5401
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:WILEY
Mailing Address - State:CO
Mailing Address - Zip Code:81092-0099
Mailing Address - Country:US
Mailing Address - Phone:719-829-4627
Mailing Address - Fax:719-829-4269
Practice Address - Street 1:302 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILEY
Practice Address - State:CO
Practice Address - Zip Code:81092
Practice Address - Country:US
Practice Address - Phone:719-829-4627
Practice Address - Fax:719-829-4269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06-8502Medicare ID - Type Unspecified