| Providence Recovery Service Of Colorado Llc | |
|
390 Yampa Boulevard Craig CO 81625-2600 | |
| (709) 824-5433 | |
| Not Available |
| Full Name | Providence Recovery Service Of Colorado Llc |
|---|---|
| Speciality | Counselor |
| Location | 390 Yampa Boulevard, Craig, Colorado |
| Authorized Official Name and Position | Tina Rene Vest (BILLING DIRECTOR) |
| Authorized Official Contact | 6626257111 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Recovery Service Of Colorado Llc Po Box 895 Craig CO 81626-0895 Ph: (970) 878-9958 | Providence Recovery Service Of Colorado Llc 390 Yampa Boulevard Craig CO 81625-2600 Ph: (709) 824-5433 |
| NPI Number | 1306408216 |
|---|---|
| Provider Enumeration Date | 07/01/2019 |
| Last Update Date | 02/26/2020 |
| Certification Date | 02/26/2020 |
| Medicare PECOS PAC ID | 8123454576 |
|---|---|
| Medicare Enrollment ID | O20200204001390 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1306408216 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Primary |
| Provider Name | Elise Sullivan |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1538365986 PECOS PAC ID: 5890933386 Enrollment ID: I20150129001612 |
| Provider Name | Kelli Dee Garcia |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1114111929 PECOS PAC ID: 5294096228 Enrollment ID: I20180307002116 |
| Provider Name | Jacquelyn Shawn Adams |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1215408893 PECOS PAC ID: 1052733995 Enrollment ID: I20200622002151 |
| Provider Name | David Mcinnis Berry |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1992024459 PECOS PAC ID: 5597954834 Enrollment ID: I20200805003271 |
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