Provider Demographics
NPI:1851693832
Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Other - Org Name:LANE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPILLANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-344-7135
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:719-632-5700
Mailing Address - Fax:719-260-1821
Practice Address - Street 1:4863 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-260-1821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK VISTA COMMUNITY HEALTH CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-24
Last Update Date:2023-03-06
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
CO05638267Medicaid
CO85225843Medicaid
CO061892Medicare Oscar/Certification
CO05638267Medicaid