Provider Demographics
NPI:1124470950
Name:COLORADO VETERANS HEALTH AND WELLNESS AGENCY
Entity type:Organization
Organization Name:COLORADO VETERANS HEALTH AND WELLNESS AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-540-2100
Mailing Address - Street 1:1330 QUAIL LAKE LOOP
Mailing Address - Street 2:SUITE 260
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4651
Mailing Address - Country:US
Mailing Address - Phone:719-540-2100
Mailing Address - Fax:
Practice Address - Street 1:1330 QUAIL LAKE LOOP
Practice Address - Street 2:SUITE 260
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4651
Practice Address - Country:US
Practice Address - Phone:719-540-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY CARE CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0053911261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)