Healthcare Provider Details

I. General information

NPI: 1689255390
Provider Name (Legal Business Name): INNER LIFE ADVENTURES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 W DRAKE RD STE 200
FORT COLLINS CO
80526-2880
US

IV. Provider business mailing address

343 W DRAKE RD STE 200
FORT COLLINS CO
80526-2880
US

V. Phone/Fax

Practice location:
  • Phone: 970-829-0478
  • Fax:
Mailing address:
  • Phone: 970-829-0478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLES S HANCOCK
Title or Position: LPC, OWNER
Credential: LPC
Phone: 970-556-4095