Basic Information
| Provider Information | |||||||||
| NPI: | 1225651839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEYSTONE ACHIEVEMENTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5526 N ACADEMY BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193015100 | ||||||||
| FaxNumber: | 7199602649 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 AEROTECH DR STE 190 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809164213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193015100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2020 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCLANE | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7193015100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1790211605 | 05 | CO | MEDICAID |