Provider Demographics
NPI:1568937639
Name:DOLORES COUNTY HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:DOLORES COUNTY HEALTH ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEHRSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-677-3628
Mailing Address - Street 1:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:DOVE CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:81324-0576
Mailing Address - Country:US
Mailing Address - Phone:970-677-3628
Mailing Address - Fax:970-677-2540
Practice Address - Street 1:101 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3562
Practice Address - Country:US
Practice Address - Phone:970-565-1800
Practice Address - Fax:970-565-1801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOLORES COUNTY HEALTH ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05682000Medicaid