Healthcare Provider Details

I. General information

NPI: 1962975813
Provider Name (Legal Business Name): MR. MICHAEL ELDEN HILLSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 IOWA AVE STE 4
COLORADO SPRINGS CO
80909-5947
US

IV. Provider business mailing address

6102 COLONY CIR
COLORADO SPRINGS CO
80919-2235
US

V. Phone/Fax

Practice location:
  • Phone: 719-358-7338
  • Fax: 844-273-2340
Mailing address:
  • Phone: 719-209-3959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACB.0008413
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: