Provider Demographics
NPI:1427722669
Name:COUNTY OF COSTILLA
Entity type:Organization
Organization Name:COUNTY OF COSTILLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-672-3465
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:CO
Mailing Address - Zip Code:81152-0099
Mailing Address - Country:US
Mailing Address - Phone:719-672-3465
Mailing Address - Fax:
Practice Address - Street 1:233 MAIN STREET, SUITE C.
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152
Practice Address - Country:US
Practice Address - Phone:719-672-3465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO013044542Medicaid