Healthcare Provider Details

I. General information

NPI: 1598816753
Provider Name (Legal Business Name): MOUNTAIN HOME MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 ILLINI DR
WOODLAND PARK CO
80863-8747
US

IV. Provider business mailing address

226 ILLINI DR
WOODLAND PARK CO
80863-8747
US

V. Phone/Fax

Practice location:
  • Phone: 719-686-7504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number State

VIII. Authorized Official

Name: DAN NICHOLSON
Title or Position: OWNER
Credential:
Phone: 719-331-9861