Provider Demographics
NPI:1679931646
Name:METRO COMMUNITY PROVIDER NETWORK, INC.
Entity Type:Organization
Organization Name:METRO COMMUNITY PROVIDER NETWORK, INC.
Other - Org Name:STRIDE CHC - JEFFERSON PLAZA FAMILY HEALTH AT JEFFERSON CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIEDERHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-761-1977
Mailing Address - Street 1:2255 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2522
Mailing Address - Country:US
Mailing Address - Phone:303-761-1977
Mailing Address - Fax:303-761-2787
Practice Address - Street 1:3595 SOUTH TELLER STREET
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2014
Practice Address - Country:US
Practice Address - Phone:303-239-9964
Practice Address - Fax:303-237-4343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METRO COMMUNITY PROVIDER NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-05
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QF0400X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60135131Medicaid