Healthcare Provider Details

I. General information

NPI: 1386063485
Provider Name (Legal Business Name): PEAK VISTA COMMUNITY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PAWNEE AVENUE
FLAGLER CO
80815
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: 719-765-4613
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
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
Identifier73855863
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: RYAN SPILLANE
Title or Position: CFO
Credential:
Phone: 719-344-7135