Provider Demographics
NPI:1487005245
Name:COUNTY OF WELD BOARD OF COUNTY COMMISSIONERS
Entity Type:Organization
Organization Name:COUNTY OF WELD BOARD OF COUNTY COMMISSIONERS
Other - Org Name:WELD COUNTY DEPT OF PUBLIC HEALTH & ENVIRONMENT INDEPENDENT LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:970-304-6410
Mailing Address - Street 1:1555 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9117
Mailing Address - Country:US
Mailing Address - Phone:970-304-6410
Mailing Address - Fax:
Practice Address - Street 1:1555 N 17TH AVE
Practice Address - Street 2:2ND FLOOR, ENVIRONMENTAL HEALTH
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9117
Practice Address - Country:US
Practice Address - Phone:970-304-6410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06D0665967291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06D0665967OtherCMS CLIA
CO35628545Medicaid
CO06D0665967OtherCMS CLIA