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Southwest Colorado Mental Health Center, Inc

Organization Active NPI Federally Qualified Health Center (FQHC) · Dove Creek, CO

NPI 1699301671 · NPPES record last updated May 27, 2021

Key facts

NPI
1699301671
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
SOUTHWEST COLORADO MENTAL HEALTH CENTER, INC
Practice address
495 W 4TH St
Dove Creek, CO 81324-4900
Phone
(970) 677-2291
NPI assigned
Mar 21, 2020
Organization subpart
Yes
Parent organization (as reported)
SOUTHWEST MENTAL HEALTH CENTER

Authorized official

Name
Shelly Burke
Title
Chief Executive Officer
Phone
(000) 000-0000

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 41

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 41

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 49

Organizations that report the same tax identification number in the National Provider Directory.

View all 49

Practitioners 73

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 73

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in CO

Federally qualified health center certification: CCN 061014

Legal name
SOUTHWEST COLORADO MENTAL HEALTH CENTER INC
Doing business as
AXIS HEALTH SYSTEM
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 9, 2020
Last certification
Jun 9, 2020
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Apr 27, 1960 in CO
Enrollment address
495 W 4TH St
Dove Creek, CO 81324-4900

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Janet Petty
Individual 		W-2 Managing Employee
Revenue Cycle Director		 Jan 1, 2025
Alyssa Nicholle Stock
Individual 		W-2 Managing Employee
Insurance Credentialing Specialist		 Sep 1, 2020
Shelly Burke
Individual 		5% Or Greater Indirect Ownership Interest
Chief Executive Officer		 Oct 11, 2000 50%
Corporate Officer
Chief Executive Officer		 Jan 6, 2014 50%
Corporate Director
Chief Executive Officer		 Jan 6, 2014 50%
W-2 Managing Employee
Chief Executive Officer		 Oct 11, 2000
Darla Ballard
Individual 		Contracted Managing Employee
Credentialing Manager		 Jan 1, 2025

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Axis Health System
Pagosa Springs, CO · CCN 061028		 Federally qualified health center Operational/Managerial Control Oct 7, 2021
Axis Health System
Durango, CO · CCN 061074		 Federally qualified health center Operational/Managerial Control Oct 7, 2021
Axis Health System
Gunnison, CO · CCN 061073		 Federally qualified health center Operational/Managerial Control Oct 7, 2021
Axis Health System
Telluride, CO · CCN 061082		 Federally qualified health center Operational/Managerial Control Oct 7, 2021

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040326001177 CO Part B Supplier - Clinic/Group Practice 9133011802 Receives reassigned benefits from 95 practitioners
46 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gunnison, CO; Montrose, CO; Norwood, CO; Pagosa Springs, CO; Telluride, CO; Crested Butte, CO; Durango, CO; Dove Creek, CO…
O20200611002589 CO Part a Provider - Federally Qualified Health Center (FQHC) 9133011802 Practice locations: Dove Creek, CO

National Provider Directory

Tax ID family
Pinon Mesa Guidance Cen (50 organizations share this tax ID)
Part of
Pinon Mesa Guidance Cen

Locations

495 W 4th St
Dove Creek, CO 81324
Phone (970) 677-2291

185 Suttle St
Durango, CO 81303
Phone (970) 335-2232

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Yes

Addresses

Primary practice location

495 W 4TH St
Dove Creek, CO 81324-4900

Mailing address

PO Box 1328
Durango, CO 81302-1328
Phone (970) 335-2238

Other names

  • AXIS HEALTH SYSTEM Doing business as
  • DOVE CREEK INTEGRATED HEALTHCARE Other name

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on May 27, 2021.

{
    "created_epoch": "1584748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1622073600000",
    "number": "1699301671",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1328",
            "city": "DURANGO",
            "state": "CO",
            "postal_code": "813021328",
            "telephone_number": "970-335-2238",
            "fax_number": "970-335-2438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "495 W 4TH ST",
            "city": "DOVE CREEK",
            "state": "CO",
            "postal_code": "813244900",
            "telephone_number": "970-677-2291"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHWEST COLORADO MENTAL HEALTH CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHWEST MENTAL HEALTH CENTER",
        "enumeration_date": "2020-03-21",
        "last_updated": "2021-05-27",
        "certification_date": "2021-05-27",
        "status": "A",
        "authorized_official_last_name": "BURKE",
        "authorized_official_first_name": "SHELLY",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "000-000-0000"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AXIS HEALTH SYSTEM",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "DOVE CREEK INTEGRATED HEALTHCARE",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Dove Creek, CO

All providers in Dove Creek, CO · Federally Qualified Health Center (FQHC) in Colorado

Sources for this page

Verify at the official NPI Registry.