Provider Demographics
NPI:1346783024
Name:ALTA VISTA CENTER FOR AUTISM
Entity type:Organization
Organization Name:ALTA VISTA CENTER FOR AUTISM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WINN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:303-759-1192
Mailing Address - Street 1:2695 S JERSEY ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-6321
Mailing Address - Country:US
Mailing Address - Phone:303-759-1192
Mailing Address - Fax:303-759-1194
Practice Address - Street 1:740 GUNNISON AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3222
Practice Address - Country:US
Practice Address - Phone:303-759-1192
Practice Address - Fax:303-759-1194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALTA VISTA CENTER FOR AUTISM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20770081Medicaid