Provider Demographics
NPI:1104173939
Name:STILLWATER HOME CARE AGENCY, LLC
Entity type:Organization
Organization Name:STILLWATER HOME CARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVRILOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-298-9080
Mailing Address - Street 1:10660 E BETHANY DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-2602
Mailing Address - Country:US
Mailing Address - Phone:303-753-7577
Mailing Address - Fax:719-466-6172
Practice Address - Street 1:10660 E BETHANY DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-2602
Practice Address - Country:US
Practice Address - Phone:303-753-7577
Practice Address - Fax:719-466-6172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17326265Medicaid