Provider Demographics
NPI:1922479583
Name:SAN JUAN SENTRY, LLC
Entity Type:Organization
Organization Name:SAN JUAN SENTRY, LLC
Other - Org Name:CORTEZ CAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-560-4633
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-4240
Mailing Address - Country:US
Mailing Address - Phone:970-565-6911
Mailing Address - Fax:970-565-4480
Practice Address - Street 1:108 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3532
Practice Address - Country:US
Practice Address - Phone:970-565-6911
Practice Address - Fax:970-565-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55823344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86203339Medicaid
CO39335836Medicaid