=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497463053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE LIVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2022
-----------------------------------------------------
Last Update Date | 11/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20985 E BERRY AVE
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80015-3615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-218-4905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20985 E BERRY AVE
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80015-3615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-218-4905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JORDAN E OEI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-218-4905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 347E00000X
-----------------------------------------------------
Taxonomy Name | Transportation Broker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------