Provider Demographics
NPI:1912352071
Name:MY SECOND HOME
Entity Type:Organization
Organization Name:MY SECOND HOME
Other - Org Name:MEGAN'S PLACE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:SMOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-427-1979
Mailing Address - Street 1:6175 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5146
Mailing Address - Country:US
Mailing Address - Phone:303-881-4988
Mailing Address - Fax:303-237-1043
Practice Address - Street 1:6175 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5146
Practice Address - Country:US
Practice Address - Phone:303-881-4988
Practice Address - Fax:303-237-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1655048385HR2050X, 385HR2060X, 385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child