Provider Demographics
NPI:1043349285
Name:DOLORES SCHOOL DISTRICT RE-4A
Entity type:Organization
Organization Name:DOLORES SCHOOL DISTRICT RE-4A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAID COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-588-0397
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-0727
Mailing Address - Country:US
Mailing Address - Phone:970-882-7255
Mailing Address - Fax:
Practice Address - Street 1:100 N. 6TH STREET
Practice Address - Street 2:
Practice Address - City:DOLORES
Practice Address - State:CO
Practice Address - Zip Code:81323
Practice Address - Country:US
Practice Address - Phone:970-882-7255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55508065Medicaid