Basic Information
| Provider Information | |||||||||
| NPI: | 1487260956 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH RANGE BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806319584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703472120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1309 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806313832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703472120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | POTTORFF | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9703472373 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 9000164586 | 05 | CO | MEDICAID | 1386-11 | 01 | CO | LICENSE | OTHER |