Provider Demographics
NPI:1922250976
Name:COUNTY COMMISSIONERS OF BACA
Entity Type:Organization
Organization Name:COUNTY COMMISSIONERS OF BACA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-523-6621
Mailing Address - Street 1:741 MAIN ST
Mailing Address - Street 2:SUITE #4
Mailing Address - City:SPRINGFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81073-1548
Mailing Address - Country:US
Mailing Address - Phone:719-523-6621
Mailing Address - Fax:719-523-6537
Practice Address - Street 1:741 MAIN ST
Practice Address - Street 2:SUITE #4
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073-1548
Practice Address - Country:US
Practice Address - Phone:719-523-6621
Practice Address - Fax:719-523-6537
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACA COUNTY PUBLIC HEALTH AGENCY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-21
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO172848163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04468096Medicaid
COCO04953Medicaid
CO04102OtherMEDICARE PAYER I.D.