Healthcare Provider Details

I. General information

NPI: 1235760521
Provider Name (Legal Business Name): A SAFE PLACE IN PAGOSA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 08/30/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 LEWIS STREET
PAGOSA SPRINGS CO
81147
US

IV. Provider business mailing address

PO BOX 5913
PAGOSA SPRINGS CO
81147-5913
US

V. Phone/Fax

Practice location:
  • Phone: 970-398-1636
  • Fax:
Mailing address:
  • Phone: 970-398-1636
  • 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 Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: KATELYN SIMMONS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 719-314-7383