Provider Demographics
NPI:1548393937
Name:STATE OF COLORADO
Entity Type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:COLORADO MENTAL HEALTH INSTITUTE FORT LOGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-866-7149
Mailing Address - Street 1:1600 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:719-546-4000
Mailing Address - Fax:719-546-4484
Practice Address - Street 1:3520 W OXFORD AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80236-3108
Practice Address - Country:US
Practice Address - Phone:303-866-7080
Practice Address - Fax:303-866-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0196283Q00000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32352344Medicaid