Provider Demographics
NPI:1649339516
Name:COLORADO MENTAL HEALTH INSTITUTE PUEBLO
Entity type:Organization
Organization Name:COLORADO MENTAL HEALTH INSTITUTE PUEBLO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HIPAA OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-866-5871
Mailing Address - Street 1:1600 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:303-866-7149
Mailing Address - Fax:
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:303-866-7149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF COLORADO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-07
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990000083336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03211885Medicaid
CO0607258OtherNCPDP MEDICARE PART D