Provider Demographics
NPI:1518322924
Name:HIGH PLAINS COMMUNITY HEALTH CENTER INCORPORATED
Entity Type:Organization
Organization Name:HIGH PLAINS COMMUNITY HEALTH CENTER INCORPORATED
Other - Org Name:HOLLY HIGH PLAINS DISPENSARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-336-0261
Mailing Address - Street 1:410 WEST COLORADO
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0000
Mailing Address - Country:US
Mailing Address - Phone:719-537-6642
Mailing Address - Fax:
Practice Address - Street 1:410 WEST COLORADO
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:CO
Practice Address - Zip Code:81047-0000
Practice Address - Country:US
Practice Address - Phone:719-537-6642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
COOO.00005523336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2156199OtherPK
061953Medicare Oscar/Certification