Provider Demographics
NPI:1831312172
Name:RIO GRANDE OLTC
Entity Type:Organization
Organization Name:RIO GRANDE OLTC
Other - Org Name:RIO GRANDE COUNTY
Other - Org Type:Other Name
Authorized Official - Title/Position:LONG TERM CARE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-657-4208
Mailing Address - Street 1:925 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-3252
Mailing Address - Country:US
Mailing Address - Phone:719-657-4208
Mailing Address - Fax:
Practice Address - Street 1:925 6TH ST
Practice Address - Street 2:
Practice Address - City:DEL NORTE
Practice Address - State:CO
Practice Address - Zip Code:81132-3252
Practice Address - Country:US
Practice Address - Phone:719-657-4208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management