Provider Demographics
NPI:1073754693
Name:IOOF GRAND LODGE OF COLORADO
Entity Type:Organization
Organization Name:IOOF GRAND LODGE OF COLORADO
Other - Org Name:FRIENDSHIP HOUSE AT THE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:PRATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-275-7451
Mailing Address - Street 1:1545 PHELPS AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4650
Mailing Address - Country:US
Mailing Address - Phone:719-275-7451
Mailing Address - Fax:
Practice Address - Street 1:1020 N 15TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2344
Practice Address - Country:US
Practice Address - Phone:719-275-7451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23C967310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23C967Medicaid