Healthcare Provider Details

I. General information

NPI: 1609178524
Provider Name (Legal Business Name): PEAK VISTA COMMUNITY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 HYBROOK RD SOUTH
DIVIDE CO
80814
US

IV. Provider business mailing address

3205 N ACADEMY BLVD SUITE 130
COLORADO SPRINGS CO
80917
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax: 719-687-4457
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier87322323
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier05638267
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: RYAN SPILLANE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 719-344-7135