1700834272 NPI number — PEAK VISTA COMMUNITY HEALTH CENTERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700834272 NPI number — PEAK VISTA COMMUNITY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK VISTA COMMUNITY HEALTH CENTERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700834272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3205 N ACADEMY BLVD
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-344-6914
Provider Business Mailing Address Fax Number:
719-344-7865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 S UNION
Provider Second Line Business Practice Location Address:
GARDEN LEVEL
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-632-5700
Provider Business Practice Location Address Fax Number:
719-228-6655
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FITZWATER
Authorized Official First Name:
BRADACH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
719-344-6188

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03000221 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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