Provider Demographics
NPI:1033163662
Name:MOUNTAIN CREEK HOME HEALTH, INC.
Entity Type:Organization
Organization Name:MOUNTAIN CREEK HOME HEALTH, INC.
Other - Org Name:MOUNTAIN CREEK HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-478-5958
Mailing Address - Street 1:601 S ALBERT AVE
Mailing Address - Street 2:
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-2246
Mailing Address - Country:US
Mailing Address - Phone:719-738-5707
Mailing Address - Fax:719-738-1933
Practice Address - Street 1:601 S ALBERT AVE
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-2246
Practice Address - Country:US
Practice Address - Phone:719-738-5707
Practice Address - Fax:719-738-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24382868Medicaid
CO24382868Medicaid