1992078216 NPI number — INTERMOUNTAIN COMMUNITY SUPPORT AND SERVICES, LLC

Table of content: DR. ARIELLE BLAKE BERGMAN M.D. (NPI 1750778866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992078216 NPI number — INTERMOUNTAIN COMMUNITY SUPPORT AND SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN COMMUNITY SUPPORT AND SERVICES, LLC
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:
1992078216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12818 NEWPORT WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THORNTON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80602-6955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-885-3299
Provider Business Mailing Address Fax Number:
720-242-9089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12818 NEWPORT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THORNTON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80602-6955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-885-3299
Provider Business Practice Location Address Fax Number:
720-242-9089
Provider Enumeration Date:
02/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LANG
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
303-885-3299

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , 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)





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