Healthcare Provider Details

I. General information

NPI: 1376273003
Provider Name (Legal Business Name): CBLG RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 SWOPE AVENUE
COLORADO SPRINGS CO
80909-2846
US

IV. Provider business mailing address

2120 E LA SALLE STREET
COLORADO SPRINGS CO
80909-2218
US

V. Phone/Fax

Practice location:
  • Phone: 719-466-4809
  • Fax: 719-368-8399
Mailing address:
  • Phone: 719-466-4809
  • Fax: 719-368-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JACEY BOMAN
Title or Position: COMPLIANCE COORDINATOR
Credential:
Phone: 719-466-4809