Provider Demographics
NPI:1457411035
Name:SAN JUAN BASIN HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:SAN JUAN BASIN HEALTH DEPARTMENT
Other - Org Name:SAN JUAN BASIN HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-247-5702
Mailing Address - Street 1:281 SAWYER DR.
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-3409
Mailing Address - Country:US
Mailing Address - Phone:970-247-5702
Mailing Address - Fax:970-247-9126
Practice Address - Street 1:281 SAWYER DR
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-3409
Practice Address - Country:US
Practice Address - Phone:970-247-5702
Practice Address - Fax:970-247-9126
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN BASIN HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-12
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006664Medicaid