Provider Demographics
NPI:1689672255
Name:WEST CUSTER COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:WEST CUSTER COUNTY HOSPITAL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-783-2380
Mailing Address - Street 1:704 EDWARDS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTCLIFFE
Mailing Address - State:CO
Mailing Address - Zip Code:81252-8588
Mailing Address - Country:US
Mailing Address - Phone:719-783-2380
Mailing Address - Fax:719-783-2377
Practice Address - Street 1:704 EDWARDS AVE
Practice Address - Street 2:
Practice Address - City:WESTCLIFFE
Practice Address - State:CO
Practice Address - Zip Code:81252-8588
Practice Address - Country:US
Practice Address - Phone:719-783-2380
Practice Address - Fax:719-783-2377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST CUSTER COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-08
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0178261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05684006Medicaid
CO=========002OtherROCKY MOUNTAIN HEALTH PLA
063804Medicare ID - Type Unspecified
CO05684006Medicaid