Provider Demographics
NPI:1598201618
Name:COLORADO SPRINGS INDEPENDENCE CENTER
Entity Type:Organization
Organization Name:COLORADO SPRINGS INDEPENDENCE CENTER
Other - Org Name:THE INDEPENDENCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:INDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-471-8181
Mailing Address - Street 1:729 S TEJON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-4041
Mailing Address - Country:US
Mailing Address - Phone:719-471-8181
Mailing Address - Fax:719-471-7829
Practice Address - Street 1:729 S TEJON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4041
Practice Address - Country:US
Practice Address - Phone:719-471-8181
Practice Address - Fax:719-471-7829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9807849251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05700067Medicaid
CO87600561Medicaid
CO05700067Medicaid