Provider Demographics
NPI:1962522235
Name:DEVELOPMENTAL DISABILITIES CENTER
Entity type:Organization
Organization Name:DEVELOPMENTAL DISABILITIES CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:NEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-665-7789
Mailing Address - Street 1:1400 DIXON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2790
Mailing Address - Country:US
Mailing Address - Phone:303-665-7789
Mailing Address - Fax:303-665-2648
Practice Address - Street 1:1960 KEN PRATT BLVD STE D
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6045
Practice Address - Country:US
Practice Address - Phone:303-776-2388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09143249Medicaid