Provider Demographics
NPI:1174765366
Name:INN BETWEEN
Entity type:Organization
Organization Name:INN BETWEEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-432-5164
Mailing Address - Street 1:4851 INDEPENDENCE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6712
Mailing Address - Country:US
Mailing Address - Phone:303-425-0300
Mailing Address - Fax:303-432-5071
Practice Address - Street 1:10295 W KEENE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-1104
Practice Address - Country:US
Practice Address - Phone:303-980-4082
Practice Address - Fax:303-980-4084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON CENTER FOR MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-02
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO150413261QR0405X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45175233Medicaid
CO9000175762Medicaid