Provider Demographics
NPI:1447622634
Name:TED HERNANDEZ INC
Entity type:Organization
Organization Name:TED HERNANDEZ INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-545-4057
Mailing Address - Street 1:105 LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1855
Mailing Address - Country:US
Mailing Address - Phone:719-545-4057
Mailing Address - Fax:
Practice Address - Street 1:105 LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1855
Practice Address - Country:US
Practice Address - Phone:719-545-4057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15431061Medicaid