Healthcare Provider Details

I. General information

NPI: 1992078216
Provider Name (Legal Business Name): INTERMOUNTAIN COMMUNITY SUPPORT AND SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12818 NEWPORT WAY
THORNTON CO
80602-6955
US

IV. Provider business mailing address

12818 NEWPORT WAY
THORNTON CO
80602-6955
US

V. Phone/Fax

Practice location:
  • Phone: 303-885-3299
  • Fax: 720-242-9089
Mailing address:
  • Phone: 303-885-3299
  • Fax: 720-242-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JEREMY ROBERT LANG
Title or Position: CO-OWNER
Credential:
Phone: 303-885-3299