Provider Demographics
NPI:1164456828
Name:BACA GRANDE PROPERTY OWNERS ASSOCIATION
Entity type:Organization
Organization Name:BACA GRANDE PROPERTY OWNERS ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:719-256-4171
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:68575 COUNTY ROAD T
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-0237
Mailing Address - Country:US
Mailing Address - Phone:719-256-4171
Mailing Address - Fax:719-256-4173
Practice Address - Street 1:68575 COUNTY RD T
Practice Address - Street 2:
Practice Address - City:CRESTONE
Practice Address - State:CO
Practice Address - Zip Code:81131-0237
Practice Address - Country:US
Practice Address - Phone:719-256-4171
Practice Address - Fax:719-256-4173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06001143Medicaid
CO60393Medicare PIN