Basic Information
| Provider Information | |||||||||
| NPI: | 1316374283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST COLORADO MENTAL HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA PLATA INTEGRATED HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1328 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813021328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352238 | ||||||||
| FaxNumber: | 9703352438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1970 E 3RD AVE | ||||||||
| Address2: | UNIT 1 LOWER LEVEL | ||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352288 | ||||||||
| FaxNumber: | 9703352280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2013 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 0000000000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST COLORADO MENTAL HEALTH CENTER, INC. | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.