Provider Demographics
NPI:1083908024
Name:CLINICA COLORADO
Entity Type:Organization
Organization Name:CLINICA COLORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-388-6491
Mailing Address - Street 1:8300 ALCOTT ST STE 300
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-4030
Mailing Address - Country:US
Mailing Address - Phone:720-443-8461
Mailing Address - Fax:720-923-1223
Practice Address - Street 1:8300 ALCOTT ST STE 300
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-4030
Practice Address - Country:US
Practice Address - Phone:720-443-8461
Practice Address - Fax:833-992-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20368261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28025075Medicaid