Provider Demographics
NPI:1114009198
Name:SENIOR HARBORS, INC.
Entity Type:Organization
Organization Name:SENIOR HARBORS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:719-320-3648
Mailing Address - Street 1:3031 NORWICH AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1435
Mailing Address - Country:US
Mailing Address - Phone:719-320-3648
Mailing Address - Fax:719-543-6432
Practice Address - Street 1:2118 CHATALET LANE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:719-320-3648
Practice Address - Fax:719-543-6432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23489367Medicaid
COC539378Medicare ID - Type Unspecified
CO23489367Medicaid