Healthcare Provider Details

I. General information

NPI: 1871156331
Provider Name (Legal Business Name): MESA DEVELOPMENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 WELLINGTON AVE
GRAND JUNCTION CO
81501-6126
US

IV. Provider business mailing address

790 WELLINGTON AVE
GRAND JUNCTION CO
81501-6126
US

V. Phone/Fax

Practice location:
  • Phone: 970-243-3702
  • Fax:
Mailing address:
  • Phone: 970-243-3702
  • Fax:

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: CHRISTOPHER BRANDON BERGQUIST
Title or Position: CFO
Credential:
Phone: 970-256-8603