Basic Information
Provider Information | |||||||||
NPI: | 1659606580 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEAK VISTA COMMUNITY HEALTH CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CRIPPLE CREEK-VICTOR MOUNTAIN HEALTH CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3205 N ACADEMY BLVD STE 130 | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809175152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196325700 | ||||||||
FaxNumber: | 7193447865 | ||||||||
Practice Location | |||||||||
Address1: | 412 NORTH C STREET | ||||||||
Address2: |   | ||||||||
City: | CRIPPLE CREEK | ||||||||
State: | CO | ||||||||
PostalCode: | 80813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7196899230 | ||||||||
FaxNumber: | 7196899236 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2009 | ||||||||
LastUpdateDate: | 08/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NARVET | ||||||||
AuthorizedOfficialFirstName: | TRACY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7193446188 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PEAK VISTA COMMUNITY HEALTH CENTERS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 18Q653 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 05638267 | 05 | CO |   | MEDICAID |