Provider Demographics
NPI:1326170739
Name:STATE OF COLORADO
Entity Type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HIPAA PRIVACY & SECURITY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:FOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-866-5871
Mailing Address - Street 1:1600 WEST 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-546-4000
Mailing Address - Fax:719-546-4982
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:719-546-4000
Practice Address - Fax:719-546-4982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0236283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05078001Medicaid
CO05078001Medicaid