Provider Demographics
NPI:1114221678
Name:IDEA-THORNTON
Entity type:Organization
Organization Name:IDEA-THORNTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AVINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-477-8280
Mailing Address - Street 1:9051 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4335
Mailing Address - Country:US
Mailing Address - Phone:303-996-9966
Mailing Address - Fax:
Practice Address - Street 1:9051 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4335
Practice Address - Country:US
Practice Address - Phone:303-996-9966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDEA FORUM INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-27
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000149330Medicaid