Healthcare Provider Details

I. General information

NPI: 1265891162
Provider Name (Legal Business Name): INNERCHANGE VIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 MAXWELL AVE SUITE 200
BOULDER CO
80304-4185
US

IV. Provider business mailing address

5500 MING AVE STE 410
BAKERSFIELD CA
93309-4631
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-2516
  • Fax: 303-449-4341
Mailing address:
  • Phone: 661-622-4132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LAURA J BROWN
Title or Position: VP OF REVENUE CYCLE MANAGEMENT
Credential:
Phone: 661-829-4060