Basic Information
Provider Information | |||||||||
NPI: | 1548932551 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTH SOLUTIONS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RESPITE SUITE 104 | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 41 MONTEBELLO RD STE 204 | ||||||||
Address2: |   | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810011379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195452746 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 41 MONTEBELLO RD STE 104 | ||||||||
Address2: |   | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810011366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195452746 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2021 | ||||||||
LastUpdateDate: | 06/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUDNIK | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7194231341 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HEALTH SOLUTIONS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BS | ||||||||
NPICertificationDate: | 06/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 385H00000X |   |   | Y |   | Respite Care Facility | Respite Care |   |
No ID Information.