Basic Information
| Provider Information | |||||||||
| NPI: | 1124764774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST COLORADO MENTAL HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1328 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813021328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352342 | ||||||||
| FaxNumber: | 9703352438 | ||||||||
| Practice Location | |||||||||
| Address1: | 238 E. COLORADO AVE, SECOND FLOOR | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | TELLURIDE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702523200 | ||||||||
| FaxNumber: | 9703691261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2022 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 0000000000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST COLORADO MENTAL HEALTH CENTER INC DBA AXIS HEALTH SYSTEM | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.