Provider Demographics
NPI:1851974554
Name:SAN JUAN BOARD OF COOPERATIVE SERVICES
Entity Type:Organization
Organization Name:SAN JUAN BOARD OF COOPERATIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLEE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-588-0397
Mailing Address - Street 1:162 STEWART ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8087
Mailing Address - Country:US
Mailing Address - Phone:970-247-3261
Mailing Address - Fax:970-247-8333
Practice Address - Street 1:162 STEWART ST UNIT A
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-8087
Practice Address - Country:US
Practice Address - Phone:970-247-3261
Practice Address - Fax:970-247-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)