=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598201618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORADO SPRINGS INDEPENDENCE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2017
-----------------------------------------------------
Last Update Date | 12/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 S TEJON ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-471-8181
-----------------------------------------------------
Fax | 719-471-7829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 S TEJON ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-471-8181
-----------------------------------------------------
Fax | 719-471-7829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | INDY FRAZEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-471-8181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 9807849
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------