=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811241151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRE MOUNTAIN RESIDENTIAL TREATMENT CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2012
-----------------------------------------------------
Last Update Date | 09/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5532 US HIGHWAY 36
-----------------------------------------------------
City | ESTES PARK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80517-8834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-443-3343
-----------------------------------------------------
Fax | 970-577-3506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5532 US HIGHWAY 36
-----------------------------------------------------
City | ESTES PARK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80517-8834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-443-3343
-----------------------------------------------------
Fax | 970-577-3506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. AARON HUEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-443-3343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------