=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578388732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTE PASS REGIONAL HEALTH SERVICE DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2024
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 RED FEATHER LN
-----------------------------------------------------
City | WOODLAND PARK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80863-1039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-687-2291
-----------------------------------------------------
Fax | 719-687-6410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 149
-----------------------------------------------------
City | WOODLAND PARK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80866-0149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-686-6692
-----------------------------------------------------
Fax | 719-687-6410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. TIMOTHY J DIENST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-686-6691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------