Provider Demographics
NPI:1104998822
Name:TELLER COUNTY
Entity type:Organization
Organization Name:TELLER COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:GOETTGE
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP, RN
Authorized Official - Phone:719-687-6416
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-0928
Mailing Address - Country:US
Mailing Address - Phone:719-687-6416
Mailing Address - Fax:719-687-6501
Practice Address - Street 1:11115 W. HIGHWAY 24
Practice Address - Street 2:UNIT 2C
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814
Practice Address - Country:US
Practice Address - Phone:719-687-6416
Practice Address - Fax:719-687-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04540548261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04540548Medicaid
CO04540548Medicaid