Basic Information
Provider Information | |||||||||
NPI: | 1720675838 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY REACH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1870 W 122ND AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 802342075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038533500 | ||||||||
FaxNumber: | 3038533702 | ||||||||
Practice Location | |||||||||
Address1: | 3031 W 76TH AVE | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 800304909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038533500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2020 | ||||||||
LastUpdateDate: | 12/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHRADER | ||||||||
AuthorizedOfficialFirstName: | RYSHELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3034126091 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY REACH CENTER, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 9000154383 | 05 | CO |   | MEDICAID |