1205967403 NPI number — AGAPE CARE LLC

Table of content: (NPI 1205967403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205967403 NPI number — AGAPE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205967403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54783 ME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLBRAN
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81624-9722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-250-5655
Provider Business Mailing Address Fax Number:
970-487-3231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54783 ME RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLBRAN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81624-9722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-250-5655
Provider Business Practice Location Address Fax Number:
970-487-3231
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
CHAN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MANAGER OF SERVICES
Authorized Official Telephone Number:
970-250-5655

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  10H563 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 63081750 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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