Provider Demographics
NPI:1629649256
Name:HOPELIGHT MEDICAL CLINIC
Entity Type:Organization
Organization Name:HOPELIGHT MEDICAL CLINIC
Other - Org Name:HOPELIGHT BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-776-2625
Mailing Address - Street 1:1351 COLLYER ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3310
Mailing Address - Country:US
Mailing Address - Phone:303-775-7723
Mailing Address - Fax:
Practice Address - Street 1:1351 COLLYER ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3310
Practice Address - Country:US
Practice Address - Phone:303-775-7723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000156356Medicaid