Healthcare Provider Details

I. General information

NPI: 1437275690
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: 03/21/2007
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 37TH ST
EVANS CO
80620-2115
US

IV. Provider business mailing address

PO BOX 200069
EVANS CO
80620-8657
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 Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. MARYLU WALTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 970-339-5360