MEDICARE: TRAIL HEAD SUPPORT SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385H00000X	Respite Care
2	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295193001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAIL HEAD SUPPORT SERVICES, LLC

Provider Business Mailing Address
First Line	:	2591 ELDORADO SPRINGS DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-5321
Country	:	US
Telephone Number	:	970-391-6838
Fax Number	:

Provider Business Practice Location Address
First Line	:	2591 ELDORADO SPRINGS DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-5321
Country	:	US
Telephone Number	:	970-391-6838
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	TOM CLINKENBEARD
Credential	:
Telephone Number	:	970-391-6838

Provider Enumeration Date	:	02/08/2016
Last Update Date	:	10/11/2016

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