Provider Demographics
NPI:1982142188
Name:SOUTHERN COLORADO DEVELOPMENTAL DISABILITIES SERVICES, INC
Entity type:Organization
Organization Name:SOUTHERN COLORADO DEVELOPMENTAL DISABILITIES SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-846-3391
Mailing Address - Street 1:1205 CONGRESS DR
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-1283
Mailing Address - Country:US
Mailing Address - Phone:719-846-3391
Mailing Address - Fax:719-846-4543
Practice Address - Street 1:415 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082
Practice Address - Country:US
Practice Address - Phone:719-846-4400
Practice Address - Fax:719-846-4543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09140070Medicaid