Provider Demographics
NPI:1639843410
Name:SAMPLE SUPPORTS, LLC
Entity Type:Organization
Organization Name:SAMPLE SUPPORTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SAMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-523-8057
Mailing Address - Street 1:620 KIMBARK ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-4911
Mailing Address - Country:US
Mailing Address - Phone:720-684-6102
Mailing Address - Fax:
Practice Address - Street 1:309 ATWOOD ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:720-684-6102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40078256Medicaid