Healthcare Provider Details

I. General information

NPI: 1255101747
Provider Name (Legal Business Name): MTX CARE COLORADO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5440 N UNION BLVD
COLORADO SPRINGS CO
80918-2049
US

IV. Provider business mailing address

225 N MILL ST STE 210
ASPEN CO
81611-1546
US

V. Phone/Fax

Practice location:
  • Phone: 970-315-2324
  • Fax:
Mailing address:
  • Phone: 970-315-2324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE WALL
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 970-404-5872