Provider Demographics
NPI:1164665956
Name:SOUTHERN COLORADO COMMUNITY ACTION AGENCY, INC.
Entity Type:Organization
Organization Name:SOUTHERN COLORADO COMMUNITY ACTION AGENCY, INC.
Other - Org Name:PEACEFUL SPIRIT TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NIEWOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-563-4517
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0800
Mailing Address - Country:US
Mailing Address - Phone:970-563-4517
Mailing Address - Fax:970-563-4504
Practice Address - Street 1:535 CANDELARIA DR
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-0800
Practice Address - Country:US
Practice Address - Phone:970-563-4517
Practice Address - Fax:970-563-4504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CO163W00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty