Provider Demographics
NPI:1669020160
Name:VCPHCS XII, LLC
Entity Type:Organization
Organization Name:VCPHCS XII, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LICENSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEMECE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GASAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LMSW
Authorized Official - Phone:214-365-6126
Mailing Address - Street 1:5001 SPRING VALLEY RD STE 600E
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-8217
Mailing Address - Country:US
Mailing Address - Phone:214-365-6100
Mailing Address - Fax:214-365-6150
Practice Address - Street 1:4157-4159 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:214-365-6126
Practice Address - Fax:214-365-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone