Provider Demographics
NPI:1033106760
Name:STATE OF COLORADO
Entity Type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:TRINIDAD STATE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BURKHOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:719-845-2818
Mailing Address - Street 1:409 BENEDICTA AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2004
Mailing Address - Country:US
Mailing Address - Phone:719-846-9291
Mailing Address - Fax:719-845-2802
Practice Address - Street 1:409 BENEDICTA AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2004
Practice Address - Country:US
Practice Address - Phone:719-846-9291
Practice Address - Fax:719-845-2802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF COLORADO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-27
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO020796314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05654058Medicaid
CO04140687Medicaid
CO04143418Medicaid