Basic Information
| Provider Information | |||||||||
| NPI: | 1699930651 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO COMMUNITY PROVIDER NETWORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JEFFERSON HIGH SCHOOL KIDS AND TEENS HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 SOUTH BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801133611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037611977 | ||||||||
| FaxNumber: | 3037612787 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 PIERCE STREET | ||||||||
| Address2: | |||||||||
| City: | EDGEWATER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802141031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032372764 | ||||||||
| FaxNumber: | 3032370597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/01/2017 | ||||||||
| NPIReactivationDate: | 10/26/2017 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3037611977 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO COMMUNITY PROVIDER NETWORK INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 18U704 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 86828070 | 05 | CO | MEDICAID |