| Details | Last Recertification Date | Update | Recertification | 1/29/2024 10:00:29 AM | 2/10/2025 4:12:48 PM | 2/10/2025 4:12 PM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2023 3:40:02 PM | 1/29/2024 10:00:29 AM | 1/29/2024 10:00 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Boudreaux, Katie
Pharmacy Director
Peak Vista Community Health Centers
7193446269 | Boudreaux, Katie
Vice President of Pharmacy Services
Peak Vista Community Health Centers
7193446269 | 1/24/2024 1:17 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Tanaka, Joel
Interim CMO
PVCHC
7193446530 | Tanaka, Joel
Chief Medical Officer
PVCHC
7193446530 | 1/10/2024 12:24 PM |
| Addresses | Main Address | Update | Change Request |
340 Printers Pkwy
Colorado Springs, CO 80910 |
2510 E PLATTE PL
Colorado Springs, CO 80909 | 7/13/2023 5:15 PM |
| Details | Entity Subname | Update | Change Request | Mobile Health Services Van | Mobile Health Services Van 1 | 7/13/2023 5:15 PM |
| Contacts | Authorizing Official | Update | Group Change Request | Ramey, Lisa
CMDO
PVCHC
7193446455 | Tanaka, Joel
Interim CMO
PVCHC
7193446530 | 5/2/2023 5:14 PM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2022 1:54:56 PM | 2/2/2023 3:40:02 PM | 2/2/2023 3:40 PM |
| Addresses | Main Address | Update | Change Request |
340 Printers Pkwy
Colorado Springs, CO 80910-3190 |
340 Printers Pkwy
Colorado Springs, CO 80910 | 10/27/2022 10:45 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Ramey, Lisa
CMDO and Interim CEO
PVCHC
7193446455 | Ramey, Lisa
CMDO
PVCHC
7193446455 | 10/10/2022 11:03 AM |
| Details | Last Recertification Date | Update | Recertification | 2/10/2021 11:10:17 AM | 2/1/2022 1:54:56 PM | 2/1/2022 1:54 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 87034786 (CO) | | 12/16/2021 4:18 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1932437746 (CO) | | 12/16/2021 4:18 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Ramey, Lisa
CMDO and Interim CEO
PVCHC
7193446453 | Ramey, Lisa
CMDO and Interim CEO
PVCHC
7193446455 | 9/17/2021 3:23 PM |
| Contacts | Primary Contact | Update | Group Change Request | Reilly, Paul
Pharmacy Director
Peak Vista Community Health Centers
7193446269 | Boudreaux, Katie
Pharmacy Director
Peak Vista Community Health Centers
7193446269 | 7/7/2021 12:39 PM |
| Contacts | Authorizing Official | Update | AO Change Request | McManus, Pamela J.
President and CEO
Peak Vista CHC
7193446453 | Ramey, Lisa
CMDO and Interim CEO
PVCHC
7193446453 | 4/7/2021 2:26 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1285964262 ( ) | | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1285964262 | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CO | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1700834272 | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CO | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1730166034 | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CO | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1912240540 | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CO | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1932437746 | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CO | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1730166034 ( ) | | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1912240540 ( ) | | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1932437746 ( ) | | 2/10/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1700834272 ( ) | | 2/10/2021 11:10 AM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 6:00:18 PM | 2/10/2021 11:10:17 AM | 2/10/2021 11:10 AM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2019 5:25:14 PM | 1/28/2020 6:00:18 PM | 1/28/2020 6:00 PM |
| Contacts | Signed By | Update | New Registration | MCMANUS, PAMELA J.
PRESIDENT AND CEO
Peak Vista CHC
7193446450 | MCMANUS, PAMELA J.
PRESIDENT AND CEO
Peak Vista CHC
7193446453 | 11/26/2019 12:49 PM |
| Contacts | Authorizing Official | Update | Change Request | MCMANUS, PAMELA J.
PRESIDENT AND CEO
Peak Vista CHC
7193446450 | McManus, Pamela J.
President and CEO
Peak Vista CHC
7193446453 | 2/13/2019 8:15 AM |
| Medicaid Billing | Medicaid: Number | Update | Recertification | 27859860 | 9000143434 | 2/8/2019 5:25 PM |
| Details | Last Recertification Date | Update | Recertification | 2/16/2018 4:52:33 PM | 2/8/2019 5:25:14 PM | 2/8/2019 5:25 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 27859860 (CO) | | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 52125084 (CO) | | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 33135070 | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | CO | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 05638267 | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | CO | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 27859860 | 5/23/2018 2:47 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | CO | 5/23/2018 2:47 PM |
| Details | Last Recertification Date | Update | Recertification | 2/16/2017 12:00:00 AM | 2/16/2018 4:52:33 PM | 2/16/2018 4:52 PM |
| Contacts | Authorizing Official | Update | | MCMANUS, PAMELA J.
PRESIDENT AND CEO
7193446450 | MCMANUS, PAMELA J.
PRESIDENT AND CEO
Peak Vista CHC
7193446450 | 10/11/2017 4:20 PM |
| Contacts | Signed By | Update | | MCMANUS, PAMELA J.
PRESIDENT AND CEO
7193446450 | MCMANUS, PAMELA J.
PRESIDENT AND CEO
Peak Vista CHC
7193446450 | 10/11/2017 4:20 PM |
| Contacts | Primary Contact | Update | | Reilly, Paul
Pharmacy Director
7193446269 | Reilly, Paul
Pharmacy Director
Peak Vista Community Health Centers
7193446269 | 9/22/2017 6:29 PM |
| Addresses | Main Address | Insert | | |
340 Printers Pkwy
Colorado Springs, CO 80910-3190 | 7/24/2017 12:19 PM |
| Addresses | Billing Address | Insert | | | Peak Vista Community Health Centers
3205 N. Academy Blvd, Suite 130
Colorado Springs, CO 80917 | 7/24/2017 12:19 PM |
| Addresses | Shipping Address | Insert | | | Peak Vista CHC Pharmacy
225 S. Union Blvd
Colorado Springs, CO 80910 | 7/24/2017 12:19 PM |
| Contacts | Authorizing Official | Insert | | | MCMANUS, PAMELA J.
PRESIDENT AND CEO
7193446450 | 7/24/2017 12:19 PM |
| Contacts | Signed By | Insert | | | MCMANUS, PAMELA J.
PRESIDENT AND CEO
7193446450 | 7/24/2017 12:19 PM |
| Contacts | Primary Contact | Update | | Hahn, Rick K.
Director of Pharmacy
7193446269 | Reilly, Paul
Pharmacy Director
7193446269 | 7/24/2017 12:19 PM |
| Details | Entity Subname | Update | | Homeless Mobile Van | Mobile Health Services Van | 7/24/2017 12:19 PM |
| Details | Last Recertification Date | Update | | 2/26/2016 12:00:00 AM | 2/16/2017 12:00:00 AM | 2/16/2017 4:31 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 27859860 | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CO | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 87034786 | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CO | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 52125084 | 1/6/2017 11:30 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CO | 1/6/2017 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1912240540 | 1/6/2017 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1932437746 | 1/6/2017 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1730166034 | 10/11/2016 10:29 AM |
| Details | Last Recertification Date | Update | | 2/11/2015 12:00:00 AM | 2/26/2016 12:00:00 AM | 2/26/2016 1:40 PM |
| Details | Last Recertification Date | Update | | 2/14/2014 12:00:00 AM | 2/11/2015 12:00:00 AM | 2/11/2015 12:01 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1285964262 | 10/14/2014 1:54 PM |
| Contacts | Primary Contact | Update | | REILLY, PAUL
PHARMACY DIRECTOR
7193446269 | Hahn, Rick K.
Director of Pharmacy
7193446269 | 3/31/2014 4:25 PM |
| Details | Entity Subname | Update | | HOMELESS MOBILE VAN | Homeless Mobile Van | 3/31/2014 4:25 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/14/2014 12:00:00 AM | 2/14/2014 5:16 PM |
| Contacts | Primary Contact | Insert | | | REILLY, PAUL
PHARMACY DIRECTOR
7193446269 | 2/7/2013 2:40 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/7/2013 2:40 PM |
| Details | 340B ID | Update | | IS-FF-CH08146AE | CH08146AE | 10/18/2012 3:34 PM |
| Dates | Participating Approval Date | Update | | | 10/18/2012 12:00:00 AM | 10/18/2012 3:34 PM |
| Details | State | Update | | Pending | Active | 10/18/2012 3:34 PM |
| Dates | Start Date | Update | | | 1/1/2013 12:00:00 AM | 10/18/2012 3:34 PM |
| Details | Grant Number | Update | | H8000212 | H80CS00212 | 10/16/2012 8:00 AM |
| Details | 340B ID | Update | | ONLINE_REG | IS-FF-CH08146AE | 10/16/2012 8:00 AM |
| Details | Comments Public | Insert | | | 10/16/12 - Reviewed registration and forwarded to IS for approval. | 10/16/2012 8:00 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/8/2012 1:19 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 03000221 | 10/8/2012 1:19 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CO | 10/8/2012 1:19 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1700834272 | 10/8/2012 1:19 PM |
| Details | Last Recertification Date | Insert | | | | 10/8/2012 1:19 PM |
| Details | Grant Number | Insert | | | H8000212 | 10/8/2012 1:19 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 10/8/2012 1:19 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/8/2012 1:19 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/8/2012 1:19 PM |
| Details | Medicare Provider Number | Insert | | | | 10/8/2012 1:19 PM |
| Details | Entity Name | Insert | | | PEAK VISTA COMMUNITY HEALTH CENTERS | 10/8/2012 1:19 PM |
| Details | Program Code | Insert | | | CH | 10/8/2012 1:19 PM |
| Details | Entity Subname | Insert | | | HOMELESS MOBILE VAN | 10/8/2012 1:19 PM |
| Dates | Participating Approval Date | Insert | | | | 10/8/2012 1:19 PM |
| Details | State | Insert | | | Pending | 10/8/2012 1:19 PM |
| Dates | Registration Date | Insert | | | 10/8/2012 12:00:00 AM | 10/8/2012 1:19 PM |
| Dates | Signed By Date | Insert | | | 10/8/2012 12:00:00 AM | 10/8/2012 1:19 PM |
| Dates | Start Date | Insert | | | | 10/8/2012 1:19 PM |
| Terminations | Termination Comments | Insert | | | | 10/8/2012 1:19 PM |
| Terminations | Termination Date | Insert | | | | 10/8/2012 1:19 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/8/2012 1:19 PM |
| Terminations | Termination Reason | Insert | | | | 10/8/2012 1:19 PM |