Basic Information
| Provider Information | |||||||||
| NPI: | 1700834272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEAK VISTA COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEAK VISTA PHARMACY AT UNION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193446914 | ||||||||
| FaxNumber: | 7193447865 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 S UNION | ||||||||
| Address2: | GARDEN LEVEL | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7192286655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | FITZWATER | ||||||||
| AuthorizedOfficialFirstName: | BRADACH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7193446188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEAK VISTA COMMUNITY HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 261QF0400X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 03000221 | 05 | CO | MEDICAID |