=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811664337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EHC21 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2021
-----------------------------------------------------
Last Update Date | 08/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1751 HOVER ST # 66B4
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-7181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-237-5075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1751 HOVER ST # 66B4
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-7181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-237-5075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RYAN BADON
-----------------------------------------------------
Credential | PBT
-----------------------------------------------------
Telephone | 866-253-9266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------