Provider Demographics
NPI:1720108251
Name:DEVELOPMENTAL DISABILITIES CENTER
Entity Type:Organization
Organization Name:DEVELOPMENTAL DISABILITIES CENTER
Other - Org Name:IMAGINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:NEVINS
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:303-665-7789
Mailing Address - Street 1:1400 DIXON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2790
Mailing Address - Country:US
Mailing Address - Phone:303-665-7789
Mailing Address - Fax:303-665-2648
Practice Address - Street 1:1400 DIXON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2790
Practice Address - Country:US
Practice Address - Phone:303-665-7789
Practice Address - Fax:303-665-2648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09147240Medicaid