Healthcare Provider Details

I. General information

NPI: 1528765864
Provider Name (Legal Business Name): FORGE EVOLUTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E KIOWA ST
COLORADO SPRINGS CO
80903-1707
US

IV. Provider business mailing address

224 E KIOWA ST
COLORADO SPRINGS CO
80903-1707
US

V. Phone/Fax

Practice location:
  • Phone: 719-475-7815
  • Fax:
Mailing address:
  • Phone: 719-475-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MORGAN MOTE
Title or Position: CEO
Credential:
Phone: 719-475-7518