Healthcare Provider Details

I. General information

NPI: 1558017780
Provider Name (Legal Business Name): UPSON HALL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E KENTUCKY AVE
GLENDALE CO
80246-2009
US

IV. Provider business mailing address

295 INTERLOCKEN BLVD STE 400
BROOMFIELD CO
80021-8105
US

V. Phone/Fax

Practice location:
  • Phone: 657-304-0103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GILBERT YATES
Title or Position: CONTRACT MANAGER
Credential:
Phone: 877-262-7803