MEDICARE: MENTAL FITNESS COLORADO, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	20171759951	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1417043837	OTHER		NPPES - NPI

General Provider Information

NPI Number	:	1538673553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTAL FITNESS COLORADO, LLC

Provider Business Mailing Address
First Line	:	2627 REDWING RD STE 220
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-6331
Country	:	US
Telephone Number	:	970-682-4353
Fax Number	:	970-530-3839

Provider Business Practice Location Address
First Line	:	2627 REDWING RD STE 220
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-6331
Country	:	US
Telephone Number	:	970-682-4353
Fax Number	:	970-530-3839

Authorized Official
Title or Position	:	OWNER
Name	:	ADAM R MUSGRAVE
Credential	:	PA-C, PSYCHIATRY CAQ
Telephone Number	:	970-682-4353

Provider Enumeration Date	:	11/29/2017
Last Update Date	:	11/29/2017

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