Basic Information
Provider Information | |||||||||
NPI: | 1275756512 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHILOH HOME INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6400 W COAL MINE AVE | ||||||||
Address2: |   | ||||||||
City: | LITTLETON | ||||||||
State: | CO | ||||||||
PostalCode: | 801234501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039329599 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7623 S ESTES CT | ||||||||
Address2: |   | ||||||||
City: | LITTLETON | ||||||||
State: | CO | ||||||||
PostalCode: | 801285223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039329599 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 10/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAMIREZ | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUITVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3039329599 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 20335 | CO | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
ID Information
ID | Type | State | Issuer | Description | 84933372 | 05 | CO |   | MEDICAID |