Basic Information
| Provider Information | |||||||||
| NPI: | 1336474584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH RANGE BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806319584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703472120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703472120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2009 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | POTTORFF | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9703472373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 50655248 | 05 | CO | MEDICAID |