Basic Information
| Provider Information | |||||||||
| NPI: | 1629053731 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCL HEALTH FRONT RANGE INC | ||||||||
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| OtherOrganizationName: | WEST PINES BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8300 W 38TH AVE | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034674080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 LUTHERAN PKWY | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034254500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | WICKLUND | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | GRANT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3034258360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCL HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0083 | CO | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 458238 | 01 | CO | MEDICARE PART B | OTHER |