Organization
INDIVIDUAL CANVAS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THERESA MARIE SANDOVAL (EXECUTIVE DIRECTOR)
(719) 334-3123
Entity
Organization
Contact information
Practice address
46 REGENCY BLVD APT I, PUEBLO, CO 81005-1831
(719) 334-3123
Mailing address
46 REGENCY BLVD APT I, PUEBLO, CO 81005-1831
(719) 334-3123
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
347E00000X
Transportation Broker
—
—
Other
Enumeration date
02/20/2023
Last updated
03/13/2023
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