Provider Demographics
NPI:1407211824
Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Other - Org Name:HEALTH CENTER AT SOUTH CIRCLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:NARVET
Authorized Official - Last Name:MCMANUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-344-6188
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7865
Practice Address - Street 1:2864 S CIRCLE DR
Practice Address - Street 2:SUITE 450
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK VISTA COMMUNITY HEALTH CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-30
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QF0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638267Medicaid
CO02105055Medicaid
CO02105055Medicaid