Healthcare Provider Details

I. General information

NPI: 1013548866
Provider Name (Legal Business Name): ENVISION CREATIVE SUPPORT FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 37TH STREET
EVANS CO
80620-0069
US

IV. Provider business mailing address

PO BOX 200069
EVANS CO
80620-0069
US

V. Phone/Fax

Practice location:
  • Phone: 970-339-5360
  • Fax: 970-330-2261
Mailing address:
  • Phone: 970-339-5360
  • Fax: 970-330-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. LORI JEAN FLEMING
Title or Position: BILLING TECH
Credential:
Phone: 970-313-2628