Provider Demographics
NPI:1184623977
Name:COLUMBINE POUDRE HOME CARE, LLC
Entity type:Organization
Organization Name:COLUMBINE POUDRE HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-0198
Mailing Address - Street 1:915 CENTRE AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6045
Mailing Address - Country:US
Mailing Address - Phone:970-482-5096
Mailing Address - Fax:970-224-2518
Practice Address - Street 1:915 CENTRE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6045
Practice Address - Country:US
Practice Address - Phone:970-482-5096
Practice Address - Fax:970-224-2518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
638551OtherBCBS PROVIDER #
CO36373036Medicaid
CO29286573Medicaid
CO29286573Medicaid