Provider Demographics
NPI:1972725455
Name:COUNTY OF COSTILLA
Entity Type:Organization
Organization Name:COUNTY OF COSTILLA
Other - Org Name:COSTILLA COUNTY PUBLIC HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-672-3332
Mailing Address - Street 1:233 MAIN STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN LUIS
Mailing Address - State:CO
Mailing Address - Zip Code:81152
Mailing Address - Country:US
Mailing Address - Phone:719-672-3332
Mailing Address - Fax:719-672-3856
Practice Address - Street 1:233 MAIN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152
Practice Address - Country:US
Practice Address - Phone:719-672-3332
Practice Address - Fax:719-672-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04138640Medicaid
COC30096Medicare PIN