Healthcare Provider Details

I. General information

NPI: 1881190791
Provider Name (Legal Business Name): REHOBOTH HOME SUPPORT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12354 E CALEY AVE UNIT 201
CENTENNIAL CO
80111-6853
US

IV. Provider business mailing address

12354 E CALEY AVE UNIT 201
CENTENNIAL CO
80111-6853
US

V. Phone/Fax

Practice location:
  • Phone: 720-524-7820
  • Fax: 720-440-9154
Mailing address:
  • Phone: 720-524-7820
  • Fax: 720-440-9154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: DAWIT G MEDHIN
Title or Position: DIRECTOR
Credential:
Phone: 303-885-0183