Provider Demographics
NPI:1437845690
Name:BRAD'S HOUSE PUEBLO
Entity Type:Organization
Organization Name:BRAD'S HOUSE PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR/BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-639-3776
Mailing Address - Street 1:14960 WOODCARVER RD # 106
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2370
Mailing Address - Country:US
Mailing Address - Phone:719-639-3776
Mailing Address - Fax:
Practice Address - Street 1:422 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2128
Practice Address - Country:US
Practice Address - Phone:719-639-3776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children