Basic Information
| Provider Information | |||||||||
| NPI: | 1932211596 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIT CARSON COUNTY HEALTH SERVICES DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARKE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 182 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808071649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193469481 | ||||||||
| FaxNumber: | 7193469485 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808071649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193469481 | ||||||||
| FaxNumber: | 7193469485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRIEGEL | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193469481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 0905 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | C248008 | 01 | CO | MEDICARE PART B GROUP | OTHER | 48557226 | 05 | CO | MEDICAID |