Provider Demographics
NPI:1952589327
Name:ISLAND GROVE REGIONAL TREATMENT CENTER
Entity Type:Organization
Organization Name:ISLAND GROVE REGIONAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:P
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:970-356-6664
Mailing Address - Street 1:1260 H STREET
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631
Mailing Address - Country:US
Mailing Address - Phone:970-351-6678
Mailing Address - Fax:970-352-7457
Practice Address - Street 1:1260 H STREET
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631
Practice Address - Country:US
Practice Address - Phone:970-351-6678
Practice Address - Fax:970-352-7457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105109324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04055764Medicaid