Provider Demographics
NPI:1093776171
Name:GOODLAND ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:GOODLAND ASSISTED LIVING, LLC
Other - Org Name:WHEAT RIDGE ACRES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KANEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-589-2063
Mailing Address - Street 1:2415 MULLINS AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-4274
Mailing Address - Country:US
Mailing Address - Phone:719-589-2063
Mailing Address - Fax:719-589-8891
Practice Address - Street 1:707 WHEAT RIDGE CIR
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-2256
Practice Address - Country:US
Practice Address - Phone:785-899-0100
Practice Address - Fax:785-899-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN091002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility