Provider Demographics
NPI:1235482415
Name:BRAIN DEVELOPMENT CENTERS OF COLORADO
Entity Type:Organization
Organization Name:BRAIN DEVELOPMENT CENTERS OF COLORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDEE
Authorized Official - Middle Name:PHYLLIS
Authorized Official - Last Name:VAN NESS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:719-375-1788
Mailing Address - Street 1:4740 FLINTRIDGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4253
Mailing Address - Country:US
Mailing Address - Phone:719-375-1788
Mailing Address - Fax:719-358-7756
Practice Address - Street 1:4740 FLINTRIDGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4253
Practice Address - Country:US
Practice Address - Phone:719-375-1788
Practice Address - Fax:719-358-7756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty