Healthcare Provider Details

I. General information

NPI: 1659738243
Provider Name (Legal Business Name): CENTENNIAL COMMUNITY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 E PIKES PEAK AVE
COLORADO SPRINGS CO
80903-3637
US

IV. Provider business mailing address

101 CEMETERY RD
AURORA TX
76078-4503
US

V. Phone/Fax

Practice location:
  • Phone: 940-597-5382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHEA ENOS
Title or Position: OWNER
Credential:
Phone: 940-597-5382