=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477346203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MTX CARE COLORADO, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2025
-----------------------------------------------------
Last Update Date | 05/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 W LITTLETON BLVD STE 320C
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80120-2225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-315-2324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 N MILL ST STE 210
-----------------------------------------------------
City | ASPEN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81611-1546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LAWRENCE WALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-315-2324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------