=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295333284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSCIOUS RESOURCES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2020
-----------------------------------------------------
Last Update Date | 10/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1144 PRINCETON DR
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80503-3653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-204-0024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1144 PRINCETON DR
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80503-3653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-204-0024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MS. MELODY ANN LEACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-204-0024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------