Provider Demographics
NPI:1548479561
Name:BAL SWAN CHILDREN'S CENTER
Entity type:Organization
Organization Name:BAL SWAN CHILDREN'S CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CONLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-466-6308
Mailing Address - Street 1:1145 E 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1301
Mailing Address - Country:US
Mailing Address - Phone:303-466-6308
Mailing Address - Fax:303-466-1224
Practice Address - Street 1:1145 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1301
Practice Address - Country:US
Practice Address - Phone:303-466-6308
Practice Address - Fax:303-466-1224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08103747Medicaid