Provider Demographics
NPI:1700834272
Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Other - Org Name:PEAK VISTA PHARMACY AT UNION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRADACH
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-344-6188
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917
Mailing Address - Country:US
Mailing Address - Phone:719-344-6914
Mailing Address - Fax:719-344-7865
Practice Address - Street 1:225 S UNION
Practice Address - Street 2:GARDEN LEVEL
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-228-6655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK VISTA COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-05
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QF0400X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03000221Medicaid
COC92908Medicare UPIN