Healthcare Provider Details

I. General information

NPI: 1235853110
Provider Name (Legal Business Name): MOUNTAIN FREEDOM CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 WHITNEY PL
BOULDER CO
80305-6710
US

IV. Provider business mailing address

4265 WHITNEY PL
BOULDER CO
80305-6710
US

V. Phone/Fax

Practice location:
  • Phone: 443-812-6652
  • Fax:
Mailing address:
  • Phone: 443-812-6652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. DEANA LOUISE CAIRO
Title or Position: OWNER
Credential: PA-C
Phone: 443-812-6652