Provider Demographics
NPI:1023215472
Name:OTERO COUNTY HEALTH DEPARTMENT
Entity type:Organization
Organization Name:OTERO COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORENE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-383-3040
Mailing Address - Street 1:13 WEST THIRD ST.
Mailing Address - Street 2:ROOM 111
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-1691
Mailing Address - Country:US
Mailing Address - Phone:719-383-3040
Mailing Address - Fax:719-383-3060
Practice Address - Street 1:13 WEST THIRD ST.
Practice Address - Street 2:ROOM 111
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1691
Practice Address - Country:US
Practice Address - Phone:719-383-3040
Practice Address - Fax:719-383-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04413092261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07396187Medicaid
CO07321771Medicaid
CO07452618Medicaid