Basic Information
| Provider Information | |||||||||
| NPI: | 1356954424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCK JACK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE SHANDY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 685 CITADEL DR E STE 580 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137259181 | ||||||||
| FaxNumber: | 7195994606 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N SANTA FE AVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808171738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198220550 | ||||||||
| FaxNumber: | 7195994606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | COLT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7134106889 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 103T00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 9000181601 | 05 | CO | MEDICAID |