Provider Demographics
NPI: | 1467793406 |
---|---|
Name: | COTTONWOOD INN, INC. |
Entity Type: | Organization |
Organization Name: | COTTONWOOD INN, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | JOYCE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HUMISTON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 970-516-1404 |
Mailing Address - Street 1: | 1004 E MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | CORTEZ |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 81321-3326 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 970-516-1404 |
Mailing Address - Fax: | 970-516-1400 |
Practice Address - Street 1: | 450 PROSPECTOR AVE |
Practice Address - Street 2: | |
Practice Address - City: | DURANGO |
Practice Address - State: | CO |
Practice Address - Zip Code: | 81301 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-516-1404 |
Practice Address - Fax: | 970-516-1400 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-03-14 |
Last Update Date: | 2016-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 87181762 | Medicaid | |
CO | 065411 | Medicare UPIN |