Provider Demographics
NPI:1114384476
Name:SHALOM HOME CARE CORPORATION LLC DBA SHALOM HOME CARE
Entity Type:Organization
Organization Name:SHALOM HOME CARE CORPORATION LLC DBA SHALOM HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-542-2715
Mailing Address - Street 1:134 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1907
Mailing Address - Country:US
Mailing Address - Phone:719-542-2715
Mailing Address - Fax:719-543-6358
Practice Address - Street 1:134 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1907
Practice Address - Country:US
Practice Address - Phone:719-542-2715
Practice Address - Fax:719-543-6358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO230659253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32771754Medicaid