MEDICARE: ALTACARE 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	376J00000X	Homemaker

General Provider Information

NPI Number	:	1518744838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTACARE LLC

Provider Business Mailing Address
First Line	:	301 BOARDWALK DR UNIT 270124
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80527-4004
Country	:	US
Telephone Number	:	970-795-2838
Fax Number	:

Provider Business Practice Location Address
First Line	:	4348 WINTERSTONE DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5656
Country	:	US
Telephone Number	:	970-795-2838
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	BENOON SOULONG
Credential	:
Telephone Number	:	970-795-2838

Provider Enumeration Date	:	09/11/2023
Last Update Date	:	09/13/2023

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