Healthcare Provider Details

I. General information

NPI: 1730183161
Provider Name (Legal Business Name): COMMUNITY ALCOHOL/DRUG REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 GILPIN ST
DENVER CO
80205-4015
US

IV. Provider business mailing address

3315 GILPIN ST
DENVER CO
80205-4015
US

V. Phone/Fax

Practice location:
  • Phone: 303-295-2521
  • Fax: 303-295-2326
Mailing address:
  • Phone: 303-295-2521
  • Fax: 303-295-2326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number1142-00
License Number StateCO

VIII. Authorized Official

Name: DR. JACQUES AMA OKONJI
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 303-295-2521