Healthcare Provider Details

I. General information

NPI: 1811664337
Provider Name (Legal Business Name): EHC21 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 HOVER ST # 66B4
LONGMONT CO
80501-7181
US

IV. Provider business mailing address

1751 HOVER ST # 66B4
LONGMONT CO
80501-7181
US

V. Phone/Fax

Practice location:
  • Phone: 469-237-5075
  • Fax:
Mailing address:
  • Phone: 469-237-5075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN BADON
Title or Position: CEO
Credential: PBT
Phone: 866-253-9266