Organization
STATE OF GRACE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROBERT RICHARD MAES JR. CAC III (CLINICAL DIRECTOR)
(719) 240-1799
Entity
Organization
Contact information
Practice address
720 N MAIN ST STE 330, PUEBLO, CO 81003-3047
(719) 569-7909
Mailing address
720 N MAIN ST STE 330, PUEBLO, CO 81003-3047
(719) 569-7909
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
1727-01
CO
Other
Enumeration date
10/26/2012
Last updated
04/15/2021
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