Provider Demographics
NPI:1134315237
Name:COLORADO HEALTH AND YOUTH, LLC
Entity Type:Organization
Organization Name:COLORADO HEALTH AND YOUTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:COLORADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-849-1258
Mailing Address - Street 1:507 OAKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5700
Mailing Address - Country:US
Mailing Address - Phone:813-849-1258
Mailing Address - Fax:813-661-0031
Practice Address - Street 1:507 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5700
Practice Address - Country:US
Practice Address - Phone:813-849-1258
Practice Address - Fax:813-661-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87583207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH89155Medicare UPIN