Provider Demographics
NPI:1942029459
Name:ITZA CORAZON COMMUNITY SERVICES LLC
Entity type:Organization
Organization Name:ITZA CORAZON COMMUNITY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:F
Authorized Official - Last Name:RIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:SWC, LACC
Authorized Official - Phone:530-786-9882
Mailing Address - Street 1:518 N CHELTON RD STE 210
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5256
Mailing Address - Country:US
Mailing Address - Phone:710-500-6009
Mailing Address - Fax:
Practice Address - Street 1:518 N CHELTON RD STE 210
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5256
Practice Address - Country:US
Practice Address - Phone:710-500-6009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-10
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty