Provider Demographics
NPI:1518331438
Name:POSITIVE BEHAVIORAL SERVICES OF THE FOUR CORNERS LLC
Entity Type:Organization
Organization Name:POSITIVE BEHAVIORAL SERVICES OF THE FOUR CORNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-946-1539
Mailing Address - Street 1:23 S BEECH ST STE B102
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 S BEECH ST STE B102
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3751
Practice Address - Country:US
Practice Address - Phone:970-946-1539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
CO251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO121212Medicaid