Healthcare Provider Details

I. General information

NPI: 1770021990
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: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 W ADAMS ST
TRINIDAD CO
81082-3613
US

IV. Provider business mailing address

1205 CONGRESS DR
TRINIDAD CO
81082-1283
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number050708
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier09140070
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier09144247
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MR. DUANE ROY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 719-846-4409