Basic Information
Provider Information | |||||||||
NPI: | 1144489675 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METRO COMMUNITY PROVIDER NETWORK INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STRIDE CHC - HAMPDEN & CHAMBERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2255 S ONEIDA ST | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802242522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037611977 | ||||||||
FaxNumber: | 3037612787 | ||||||||
Practice Location | |||||||||
Address1: | 15132 E HAMPDEN AVE STE G | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 800145038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037626546 | ||||||||
FaxNumber: | 3037626550 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2008 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARRIOTT | ||||||||
AuthorizedOfficialFirstName: | CHRISTI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF ORGANIZATION | ||||||||
AuthorizedOfficialTelephone: | 3037611977 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | METRO COMMUNITY PROVIDER NETWORK INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 05638291 | 05 | CO |   | MEDICAID |