Provider Demographics
NPI:1215543855
Name:NORTH RANGE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:NORTH RANGE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTORFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-347-2373
Mailing Address - Street 1:1300 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9584
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:
Practice Address - Street 1:7251 W 20TH ST UNIT C
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4626
Practice Address - Country:US
Practice Address - Phone:970-347-2120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1386-16OtherLICENSE
CO9000166446Medicaid