Provider Demographics
NPI:1043713993
Name:CHARTER HEALTHCARE OF NORTHERN COLORADO, LLC
Entity Type:Organization
Organization Name:CHARTER HEALTHCARE OF NORTHERN COLORADO, LLC
Other - Org Name:PHOENIX HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-644-4965
Mailing Address - Street 1:1562 TAURUS CT
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-3280
Mailing Address - Country:US
Mailing Address - Phone:970-667-2273
Mailing Address - Fax:888-891-0585
Practice Address - Street 1:1562 TAURUS CT
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3280
Practice Address - Country:US
Practice Address - Phone:970-667-2273
Practice Address - Fax:888-891-0585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
CO04Z780253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000146914Medicaid