Healthcare Provider Details

I. General information

NPI: 1780158691
Provider Name (Legal Business Name): SECOND HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 PRINTERS PKWY
COLORADO SPRINGS CO
80910-3190
US

IV. Provider business mailing address

390 PRINTERS PKWY
COLORADO SPRINGS CO
80910-3190
US

V. Phone/Fax

Practice location:
  • Phone: 719-375-8121
  • Fax:
Mailing address:
  • Phone: 719-375-8121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GURGEN KRYLOV
Title or Position: MEMBER
Credential:
Phone: 720-448-7406