Provider Demographics
NPI:1033397088
Name:ISLAND GROVE REGIONAL TREATMENT CENTER
Entity Type:Organization
Organization Name:ISLAND GROVE REGIONAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:P
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:970-356-6664
Mailing Address - Street 1:1250 N WILSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537
Mailing Address - Country:US
Mailing Address - Phone:970-669-1700
Mailing Address - Fax:970-663-5617
Practice Address - Street 1:1250 N WILSON AVENUE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537
Practice Address - Country:US
Practice Address - Phone:970-669-1700
Practice Address - Fax:970-663-5617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105108324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33684766Medicaid