=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760840722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOSTALGIA GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2016
-----------------------------------------------------
Last Update Date | 02/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 S COLORADO BLVD STE B304
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-298-0027
-----------------------------------------------------
Fax | 303-298-0037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 S COLORADO BLVD STE B304
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-298-0027
-----------------------------------------------------
Fax | 303-298-0037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JAMES SHANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-298-0027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------