Provider Demographics
NPI:1417531849
Name:ALTA VISTA CENTER FOR AUTISM
Entity Type:Organization
Organization Name:ALTA VISTA CENTER FOR AUTISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:KIRKER
Authorized Official - Last Name:OGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-399-9203
Mailing Address - Street 1:2001 HOYT ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1639
Mailing Address - Country:US
Mailing Address - Phone:303-759-1192
Mailing Address - Fax:303-759-1194
Practice Address - Street 1:2320 W COLORADO AVE STE 125
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3355
Practice Address - Country:US
Practice Address - Phone:303-759-1192
Practice Address - Fax:303-759-1194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALTA VISTA CENTER FOR AUTISM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17770106Medicaid