Healthcare Provider Details

I. General information

NPI: 1982142188
Provider Name (Legal Business Name): SOUTHERN COLORADO DEVELOPMENTAL DISABILITIES SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S INDIANA AVE
TRINIDAD CO
81082
US

IV. Provider business mailing address

1205 CONGRESS DR
TRINIDAD CO
81082-1283
US

V. Phone/Fax

Practice location:
  • Phone: 719-846-4400
  • Fax: 719-846-4543
Mailing address:
  • Phone: 719-846-3391
  • Fax: 719-846-4543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DUANE ROY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 719-846-3391