=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093353997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICARE HOME HEALTH AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2019
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2851 S PARKER RD # 3428
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-993-6393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2851 S PARKER RD # 3428
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-993-6393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FAHRREN BOLASTIG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-499-2956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------