MEDICARE: COLORADO'S CHILDHOOD CANCER AND DISABILITIES CAMPS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist
3	103TR0400X	Rehabilitation Psychologist
4	133N00000X	Nutritionist
5	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse
6	164W00000X	Licensed Practical Nurse
7	174200000X	Meals Provider
8	177F00000X	Lodging Provider
9	251B00000X	Case Management Agency
10	251S00000X	Community/Behavioral Health Agency
11	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1023592508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO'S CHILDHOOD CANCER AND DISABILITIES CAMPS, INC.

Provider Business Mailing Address
First Line	:	530 COMMUNICATION CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-1744
Country	:	US
Telephone Number	:	719-493-0937
Fax Number	:

Provider Business Practice Location Address
First Line	:	51934 SOUTH HIGHWAY 285
Second Line	:
City	:	GRANT
State	:	CO
Zip	:	80448-8042
Country	:	US
Telephone Number	:	719-963-7528
Fax Number	:

Authorized Official
Title or Position	:	DRUG AND ALCOHOL PROGRAM MANAGER
Name	:	CHEYENNE TAYLOR GARRISON
Credential	:
Telephone Number	:	719-493-0937

Provider Enumeration Date	:	09/20/2018
Last Update Date	:	09/20/2018

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