Provider Demographics
NPI:1104357318
Name:PARENT CARE LIFE INC DBA CRESTVIEW
Entity Type:Organization
Organization Name:PARENT CARE LIFE INC DBA CRESTVIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-473-6339
Mailing Address - Street 1:1414 N HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2655
Mailing Address - Country:US
Mailing Address - Phone:719-473-6339
Mailing Address - Fax:719-448-9301
Practice Address - Street 1:1409 E BUENA VENTURA ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2824
Practice Address - Country:US
Practice Address - Phone:719-473-6339
Practice Address - Fax:719-448-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23F100310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000143722OtherHCPF PROVIDER ID