Healthcare Provider Details

I. General information

NPI: 1184201576
Provider Name (Legal Business Name): FAMILY HOME HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 38TH ST STE 101E
BOULDER CO
80301-2623
US

IV. Provider business mailing address

1650 38TH ST STE 101E
BOULDER CO
80301-2623
US

V. Phone/Fax

Practice location:
  • Phone: 720-274-5974
  • Fax: 720-274-5977
Mailing address:
  • Phone: 720-274-5974
  • Fax: 720-274-5977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
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:

# 1
Identifier43831761
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: LUTHER DWAIN STANTON
Title or Position: PRESIDENT
Credential:
Phone: 720-274-5974