Provider Demographics
NPI:1376273003
Name:CBLG RESIDENTIAL SERVICES
Entity type:Organization
Organization Name:CBLG RESIDENTIAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-466-4809
Mailing Address - Street 1:2120 E LA SALLE STREET
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2218
Mailing Address - Country:US
Mailing Address - Phone:719-466-4809
Mailing Address - Fax:719-368-8399
Practice Address - Street 1:1511 SWOPE AVENUE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2846
Practice Address - Country:US
Practice Address - Phone:719-466-4809
Practice Address - Fax:719-368-8399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELIZABETH OSTENDORF, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-15
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty