Provider Demographics
NPI:1881190791
Name:REHOBOTH HOME SUPPORT, LLC
Entity Type:Organization
Organization Name:REHOBOTH HOME SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWIT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MEDHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-885-0183
Mailing Address - Street 1:12354 E CALEY AVE UNIT 201
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-6853
Mailing Address - Country:US
Mailing Address - Phone:720-524-7820
Mailing Address - Fax:720-440-9154
Practice Address - Street 1:12354 E CALEY AVE UNIT 201
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-6853
Practice Address - Country:US
Practice Address - Phone:720-524-7820
Practice Address - Fax:720-440-9154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO320900000X, 347E00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No347E00000XTransportation ServicesTransportation BrokerGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty