Healthcare Provider Details

I. General information

NPI: 1871899302
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9029 E MISSISSIPPI AVE APT R302
DENVER CO
80247-6867
US

IV. Provider business mailing address

9029 E MISSISSIPPI AVE APT R302
DENVER CO
80247-6867
US

V. Phone/Fax

Practice location:
  • Phone: 815-793-4092
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number12111157
License Number StateCO

VIII. Authorized Official

Name: KRISTEN RIMMER
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential:
Phone: 815-793-4092