Healthcare Provider Details

I. General information

NPI: 1285181651
Provider Name (Legal Business Name): EDH SUPPORT COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 CEDAR AVE 201
BOULDER CO
80304-3157
US

IV. Provider business mailing address

67 WILD HORSE CIR
BOULDER CO
80304-0488
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-1308
  • Fax:
Mailing address:
  • Phone: 303-442-1308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training 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: JANET POWELL HENDRICKS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 303-442-1308