=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982170114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PHYSICIANS HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2018
-----------------------------------------------------
Last Update Date | 10/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 W GARDEN OF THE GODS RD SUITE F
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-434-2585
-----------------------------------------------------
Fax | 719-434-1791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905 W GARDEN OF THE GODS RD SUITE F
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-434-2585
-----------------------------------------------------
Fax | 719-434-1791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. ERIC SAMUEL GUSTAFSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-434-2585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------