MEDICARE: THH358 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1790656528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THH358 LLC

Provider Business Mailing Address
First Line	:	5219 BRADY RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-1109
Country	:	US
Telephone Number	:	719-321-9107
Fax Number	:

Provider Business Practice Location Address
First Line	:	5219 BRADY RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-1109
Country	:	US
Telephone Number	:	719-321-9107
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. STARLA OWEN
Credential	:
Telephone Number	:	719-321-9107

Provider Enumeration Date	:	09/15/2025
Last Update Date	:	09/15/2025

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