Provider Demographics
NPI:1740650431
Name:SAND AND SAGE PERSONAL CARE AGENCY
Entity type:Organization
Organization Name:SAND AND SAGE PERSONAL CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-688-9666
Mailing Address - Street 1:117 WEST ELM STREET
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052
Mailing Address - Country:US
Mailing Address - Phone:719-688-9666
Mailing Address - Fax:719-691-2132
Practice Address - Street 1:121 W BEECH ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-2731
Practice Address - Country:US
Practice Address - Phone:719-688-9666
Practice Address - Fax:719-691-2132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04S685251E00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30854369Medicaid