=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942815931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH RANGE BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2020
-----------------------------------------------------
Last Update Date | 09/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 1ST ST
-----------------------------------------------------
City | FORT LUPTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80621-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-347-2120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 N 17TH AVE
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80631-9584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-347-2120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | LARRY POTTORFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-347-2373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------