=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780158691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SECOND HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2019
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 PRINTERS PKWY
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80910-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-375-8121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 PRINTERS PKWY
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80910-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-375-8121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | GURGEN KRYLOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-448-7406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------