Basic Information
| Provider Information | |||||||||
| NPI: | 1972056547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VCPHCS X, LLC | ||||||||
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| OtherOrganizationName: | BHG FORT COLLINS TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 SPRING VALLEY RD | ||||||||
| Address2: | SUITE 600 EAST | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143656100 | ||||||||
| FaxNumber: | 2143656150 | ||||||||
| Practice Location | |||||||||
| Address1: | 2114 MIDPOINT DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703723144 | ||||||||
| FaxNumber: | 9704821921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2016 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1597-05 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM2800X | 1597-05 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | 1597-05 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 44973365 | 05 | CO | MEDICAID |