Basic Information
| Provider Information | |||||||||
| NPI: | 1316906886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY REACH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY REACH CENTER, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8931 HURON ST | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802606806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038533500 | ||||||||
| FaxNumber: | 3034269340 | ||||||||
| Practice Location | |||||||||
| Address1: | 8931 HURON ST | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802606806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038533500 | ||||||||
| FaxNumber: | 3034269340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUCET | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3038533500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 04010096 | 05 | CO | MEDICAID |