Provider Demographics
NPI:1780724559
Name:CENTENNIAL HOME CARE, LLC
Entity type:Organization
Organization Name:CENTENNIAL HOME CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-826-2421
Mailing Address - Street 1:600 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-2018
Mailing Address - Country:US
Mailing Address - Phone:970-824-6882
Mailing Address - Fax:970-824-2157
Practice Address - Street 1:600 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-2018
Practice Address - Country:US
Practice Address - Phone:970-824-6882
Practice Address - Fax:970-824-2157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06D1019559251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79873341Medicaid
CO79873341Medicaid