Provider Demographics
NPI:1396995601
Name:STATE OF COLORADO
Entity type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RIZZUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-384-6822
Mailing Address - Street 1:1802 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3400
Mailing Address - Country:US
Mailing Address - Phone:719-384-3102
Mailing Address - Fax:719-384-1096
Practice Address - Street 1:1802 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3400
Practice Address - Country:US
Practice Address - Phone:719-384-3102
Practice Address - Fax:719-384-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06D1089569291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94654395Medicaid