Provider Demographics
NPI:1902875073
Name:EVANSARMYCOMMUNITYHOSPITAL
Entity Type:Organization
Organization Name:EVANSARMYCOMMUNITYHOSPITAL
Other - Org Name:DARAIMONDO MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICAL NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FARRAR
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:719-524-2087
Mailing Address - Street 1:1041 OCONNELL
Mailing Address - Street 2:
Mailing Address - City:FT. CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913
Mailing Address - Country:US
Mailing Address - Phone:719-524-2087
Mailing Address - Fax:
Practice Address - Street 1:1041 OCONNELL ST.
Practice Address - Street 2:
Practice Address - City:FT. CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-524-2087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23366261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23366Medicare UPIN