Provider Demographics
NPI:1134129034
Name:HEART OF BOARDWALK
Entity Type:Organization
Organization Name:HEART OF BOARDWALK
Other - Org Name:CHARG RESOURCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, ACSW, LCSW
Authorized Official - Phone:303-830-8805
Mailing Address - Street 1:709 E 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-2610
Mailing Address - Country:US
Mailing Address - Phone:303-830-8805
Mailing Address - Fax:303-830-8918
Practice Address - Street 1:709 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-2610
Practice Address - Country:US
Practice Address - Phone:303-830-8805
Practice Address - Fax:303-830-8918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO150402261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04008637Medicaid
CO04008637Medicaid