Basic Information
| Provider Information | |||||||||
| NPI: | 1053931501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST COLORADO MENTAL HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AXIS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1238 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813021238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352238 | ||||||||
| FaxNumber: | 9703352438 | ||||||||
| Practice Location | |||||||||
| Address1: | 691 E EMPIRE ST | ||||||||
| Address2: | |||||||||
| City: | CORTEZ | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813212802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705657946 | ||||||||
| FaxNumber: | 9705659005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2020 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 0000000000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST COLORADO MENTAL HEALTH CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.