Provider Demographics
NPI:1396035887
Name:BOONE GUEST HOME
Entity Type:Organization
Organization Name:BOONE GUEST HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-564-0163
Mailing Address - Street 1:1339 S PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1686
Mailing Address - Country:US
Mailing Address - Phone:719-564-0163
Mailing Address - Fax:719-564-0193
Practice Address - Street 1:1339 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1686
Practice Address - Country:US
Practice Address - Phone:719-564-0163
Practice Address - Fax:719-564-0193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 253J00000X
CO050615320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84622814Medicaid
CO52880711Medicaid