=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205688553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST COLORADO MENTAL HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2024
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 VILLAGE DR
-----------------------------------------------------
City | PAGOSA SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81147-8368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-264-2104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1328
-----------------------------------------------------
City | DURANGO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81302-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-335-2342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ALEX CONRAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | --
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------