Basic Information
| Provider Information | |||||||||
| NPI: | 1598890238 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARTNERSHIP FOR PROGRESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 452 | ||||||||
| Address2: | |||||||||
| City: | SWINK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810770452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198536329 | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARRICA | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7193845446 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | CACII | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 1587-02 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 1587-03 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 1587-04 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 1587-05 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 1587-06 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 1587-01 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 25106848 | 05 | CO | MEDICAID | 55708731 | 05 | CO | MEDICAID | 06252052 | 05 | CO | MEDICAID | 02829347 | 05 | CO | MEDICAID | 86730754 | 05 | CO | MEDICAID | 79106331 | 05 | CO | MEDICAID |