Provider Demographics
NPI:1104069764
Name:PEACEFUL SPIRIT/SUCAP
Entity type:Organization
Organization Name:PEACEFUL SPIRIT/SUCAP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DAHLKE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CACIII, LPC
Authorized Official - Phone:970-563-4555
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0429
Mailing Address - Country:US
Mailing Address - Phone:970-563-4555
Mailing Address - Fax:970-563-4618
Practice Address - Street 1:296 MOUACHE DRIVE
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-0429
Practice Address - Country:US
Practice Address - Phone:970-563-4555
Practice Address - Fax:970-563-4618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1390324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1390OtherCOLORADO STATE DEPARTMENT OF REGLATORY AGENCY