Basic Information
Provider Information | |||||||||
NPI: | 1326203399 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METRO COMMUNITY PROVIDER NETWORK, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STRIDE CHC - ROSE STEIN ELEMENTARY SCHOOL | ||||||||
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: | 3033606276 | ||||||||
FaxNumber: | 3037612787 | ||||||||
Practice Location | |||||||||
Address1: | 80 S TELLER ST | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802262044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032384662 | ||||||||
FaxNumber: | 3032388796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2008 | ||||||||
LastUpdateDate: | 03/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 21477558 | 05 | CO |   | MEDICAID |