Provider Demographics
NPI:1386706505
Name:COUNTY OF CHEYENNE
Entity type:Organization
Organization Name:COUNTY OF CHEYENNE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-767-5616
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE WELLS
Mailing Address - State:CO
Mailing Address - Zip Code:80810-0038
Mailing Address - Country:US
Mailing Address - Phone:719-767-5616
Mailing Address - Fax:719-767-8747
Practice Address - Street 1:560 W 6 N
Practice Address - Street 2:
Practice Address - City:CHEYENNE WELLS
Practice Address - State:CO
Practice Address - Zip Code:80810
Practice Address - Country:US
Practice Address - Phone:719-767-5616
Practice Address - Fax:719-767-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04540191Medicaid
COCOB4673Medicare PIN