Provider Demographics
NPI:1578199576
Name:FRIENDLY HARBOR
Entity Type:Organization
Organization Name:FRIENDLY HARBOR
Other - Org Name:FRIENDLY HARBOR COMMUNITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VOLUNTEER EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-214-6081
Mailing Address - Street 1:2713 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2453
Mailing Address - Country:US
Mailing Address - Phone:719-545-2564
Mailing Address - Fax:
Practice Address - Street 1:2713 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2453
Practice Address - Country:US
Practice Address - Phone:719-545-2564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-21
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty