Provider Demographics
NPI:1598203713
Name:SOUTHERN COLORADO DEVELOPMENTAL DISABILITIES SERVICES, INC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO DEVELOPMENTAL DISABILITIES SERVICES, INC
Other - Org Name:MADISON GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-846-4409
Mailing Address - Street 1:1205 CONGRESS DR
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-1283
Mailing Address - Country:US
Mailing Address - Phone:719-846-3391
Mailing Address - Fax:
Practice Address - Street 1:305 MADISON ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3736
Practice Address - Country:US
Practice Address - Phone:719-846-3391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN COLORADO DEVELOPMENTAL DISABILITIES SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-08
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 332B00000X, 347B00000X
CO050709320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09140070Medicaid
CO09144247Medicaid