Basic Information
| Provider Information | |||||||||
| NPI: | 1487220174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO COMMUNITY PROVIDER NETWORK INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STRIDE CHC - CONIFER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11030 KITTY DR | ||||||||
| Address2: | |||||||||
| City: | CONIFER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804337767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037611977 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11030 KITTY DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CONIFER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804337767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033606276 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2021 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARRIOTT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF ORGANIZATION | ||||||||
| AuthorizedOfficialTelephone: | 3037611977 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 9000202877 | 05 | CO | MEDICAID |