Healthcare Provider Details

I. General information

NPI: 1174765366
Provider Name (Legal Business Name): INN BETWEEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 12/18/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10295 W KEENE AVE
LAKEWOOD CO
80235-1104
US

IV. Provider business mailing address

4851 INDEPENDENCE ST STE 200
WHEAT RIDGE CO
80033-6712
US

V. Phone/Fax

Practice location:
  • Phone: 303-980-4082
  • Fax: 303-980-4084
Mailing address:
  • Phone: 303-425-0300
  • Fax: 303-432-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number150413
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID A GOFF
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 303-432-5164