Basic Information
| Provider Information | |||||||||
| NPI: | 1568786960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART OF BOARDWALK - CHARG RESOURCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802052526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032936515 | ||||||||
| FaxNumber: | 3032916900 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802052526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032936515 | ||||||||
| FaxNumber: | 3032916900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2010 | ||||||||
| LastUpdateDate: | 03/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | BURGESS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3038308805 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1241 | CO | Y | Agencies | Community/Behavioral Health |
No ID Information.