=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760145064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEVELOPMENTAL DISABILITIES CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2021
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 DIXON AVE
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80026-2790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-665-7789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 DIXON AVE
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80026-2790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-665-7789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO AND CFO
-----------------------------------------------------
Name | ROBIN GREY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-641-6342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------