Healthcare Provider Details

I. General information

NPI: 1285019430
Provider Name (Legal Business Name): ROCKY MOUNTIAN YOUTH CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9197 GRANT ST SUITE 200
THORNTON CO
80229-4329
US

IV. Provider business mailing address

9197 GRANT ST SUITE 100
THORNTON CO
80229-4329
US

V. Phone/Fax

Practice location:
  • Phone: 303-450-3690
  • Fax: 303-962-1511
Mailing address:
  • Phone: 303-450-3690
  • Fax: 303-962-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4312
License Number StateCO

VIII. Authorized Official

Name: SOPHIA MEHARENA
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 303-450-3690