Basic Information
| Provider Information | |||||||||
| NPI: | 1033755392 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO COMMUNITY PROVIDER NETWORK, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STRIDE CHC - UNION SQUARE HEALTH PLAZA DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 S ONEIDA ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802242522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033606276 | ||||||||
| FaxNumber: | 3033430247 | ||||||||
| Practice Location | |||||||||
| Address1: | 12055 W 2ND PL # 200 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033606276 | ||||||||
| FaxNumber: | 3033430247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TREVINO | ||||||||
| AuthorizedOfficialFirstName: | YOLANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS MANGER | ||||||||
| AuthorizedOfficialTelephone: | 3037612153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO COMMUNITY PROVIDER NETWORK, INC. | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.