Basic Information
| Provider Information | |||||||||
| NPI: | 1316233174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO COMMUNITY PROVIDER NETWORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INDEPENDENCE HEALTH CENTER AT JEFFERSON CENTER FOR MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 S ONEIDA ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802242522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037611977 | ||||||||
| FaxNumber: | 3037612787 | ||||||||
| Practice Location | |||||||||
| Address1: | 4851 INDEPENDENCE STREET | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032747094 | ||||||||
| FaxNumber: | 3032747095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIEDERHOLT | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3037611977 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO COMMUNITY PROVIDER NETWORK, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 58038230 | 05 | CO | MEDICAID |