Provider Demographics
NPI:1780158691
Name:SECOND HOME LLC
Entity type:Organization
Organization Name:SECOND HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GURGEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRYLOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-448-7406
Mailing Address - Street 1:390 PRINTERS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3190
Mailing Address - Country:US
Mailing Address - Phone:719-375-8121
Mailing Address - Fax:
Practice Address - Street 1:390 PRINTERS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3190
Practice Address - Country:US
Practice Address - Phone:719-375-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care