Healthcare Provider Details

I. General information

NPI: 1285492942
Provider Name (Legal Business Name): PROVIDENCE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 N BROADWAY
DENVER CO
80203-3920
US

IV. Provider business mailing address

357 N BROADWAY
DENVER CO
80203-3920
US

V. Phone/Fax

Practice location:
  • Phone: 303-860-8404
  • Fax:
Mailing address:
  • Phone: 303-860-8404
  • 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 Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DEREK KUYKENDALL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 303-860-8484