Provider Demographics
NPI:1013040385
Name:THE MOUNTAIN STAR CENTER
Entity Type:Organization
Organization Name:THE MOUNTAIN STAR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HIPAA OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-866-5871
Mailing Address - Street 1:1600 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:719-546-4000
Mailing Address - Fax:719-546-4484
Practice Address - Street 1:3520 W OXFORD AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80236-3108
Practice Address - Country:US
Practice Address - Phone:303-866-7080
Practice Address - Fax:303-866-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13363320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18751067Medicaid