Basic Information
| Provider Information | |||||||||
| NPI: | 1265565824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CENTRAL MENTAL HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Practice Location | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7192752351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST CENTRAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1668-00 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | 1306 | CO | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 04200093 | 05 | CO | MEDICAID |