Basic Information
Provider Information | |||||||||
NPI: | 1770006587 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST CENTRAL MENTAL HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOLVISTA HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3225 INDEPENDENCE RD | ||||||||
Address2: |   | ||||||||
City: | CANON CITY | ||||||||
State: | CO | ||||||||
PostalCode: | 812129380 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7192752351 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 VESTA RD | ||||||||
Address2: |   | ||||||||
City: | SALIDA | ||||||||
State: | CO | ||||||||
PostalCode: | 812019327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195396502 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2017 | ||||||||
LastUpdateDate: | 10/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TURNER | ||||||||
AuthorizedOfficialFirstName: | BRAIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7192752351 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WEST CENTRAL INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QM0801X | 1668-01 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 04200093 | 05 | CO |   | MEDICAID |