Provider Demographics
NPI:1679115281
Name:SECOND HOME LLC
Entity Type:Organization
Organization Name:SECOND HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GURGEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRYLOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-448-7406
Mailing Address - Street 1:550 S ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2636
Mailing Address - Country:US
Mailing Address - Phone:719-375-8121
Mailing Address - Fax:
Practice Address - Street 1:550 S ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2636
Practice Address - Country:US
Practice Address - Phone:719-375-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SECOND HOME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-15
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)