MEDICARE: KOTILLO BLESSING CARE 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	251C00000X	Developmentally Disabled Services Day Training Agency
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1487368601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOTILLO BLESSING CARE LLC

Provider Business Mailing Address
First Line	:	4318 CEYLON CT
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80249-6540
Country	:	US
Telephone Number	:	720-327-8315
Fax Number	:

Provider Business Practice Location Address
First Line	:	4318 CEYLON CT
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80249-6540
Country	:	US
Telephone Number	:	720-327-8315
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MACHANDOQUE KOTILO
Credential	:
Telephone Number	:	720-327-8315

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	01/11/2023

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