Basic Information
| Provider Information | |||||||||
| NPI: | 1669020160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VCPHCS XII, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 SPRING VALLEY RD STE 600E | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752448217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143656100 | ||||||||
| FaxNumber: | 2143656150 | ||||||||
| Practice Location | |||||||||
| Address1: | 4157-4159 CENTENNIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143656126 | ||||||||
| FaxNumber: | 2143656150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | GASAWAY | ||||||||
| AuthorizedOfficialFirstName: | JEMECE | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 2143656126 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSW. LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.