Provider Demographics
NPI:1639934169
Name:ACQUA RECOVERY COLORADO
Entity Type:Organization
Organization Name:ACQUA RECOVERY COLORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LISTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-987-2583
Mailing Address - Street 1:PO BOX 982437
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-2437
Mailing Address - Country:US
Mailing Address - Phone:970-987-2583
Mailing Address - Fax:
Practice Address - Street 1:3932 JOHN F KENNEDY PKWY
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3084
Practice Address - Country:US
Practice Address - Phone:970-987-2583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health