Provider Demographics
NPI:1740864875
Name:INTEGRATED LIFE CHOICES (ILC)
Entity type:Organization
Organization Name:INTEGRATED LIFE CHOICES (ILC)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY IMPROVEMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-484-8990
Mailing Address - Street 1:PO BOX 80728
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68501-0728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7222 COMMERCE CENTER DR STE 175
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2226
Practice Address - Country:US
Practice Address - Phone:719-465-1538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED LIFE CHOICES (ILC)
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36358851Medicaid