Basic Information
| Provider Information | |||||||||
| NPI: | 1477679959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO COMMUNITY PROVIDER NETWORK INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | STRIDE COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 S ONEIDA ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802242522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037611977 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2255 S ONEIDA ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802242522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037611977 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARRIOTT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR OF OE/BI | ||||||||
| AuthorizedOfficialTelephone: | 3037611977 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2022 | ||||||||
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 | 17250048 | 05 | CO | MEDICAID | 05638754 | 05 | CO | MEDICAID | 05638291 | 05 | CO | MEDICAID | 84656581 | 05 | CO | MEDICAID | 86401360 | 05 | CO | MEDICAID | 9000206459 | 05 | CO | MEDICAID | 01552511 | 05 | CO | MEDICAID | 86602373 | 05 | CO | MEDICAID | 9000207259 | 05 | CO | MEDICAID | 31601049 | 05 | CO | MEDICAID | 9000160508 | 05 | CO | MEDICAID | 9000183608 | 05 | CO | MEDICAID | 9000202877 | 05 | CO | MEDICAID | 21477558 | 05 | CO | MEDICAID | 49105060 | 05 | CO | MEDICAID | 69585547 | 05 | CO | MEDICAID | 9000183615 | 05 | CO | MEDICAID | 9000190852 | 05 | CO | MEDICAID |