=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659815769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIOLET MOUNTAIN LIFE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2016
-----------------------------------------------------
Last Update Date | 12/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1353 S 8TH ST SUITE 102
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80905-7320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-201-5735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1353 S 8TH ST SUITE 102
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80905-7320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-201-5735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DR. GLORIA J. RYDER
-----------------------------------------------------
Credential | L.M.F.T.
-----------------------------------------------------
Telephone | 719-201-5735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 0000390
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------